- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $623.46 / $1,122.23
| Facility | | $519.54 | $623.46 | $1,122.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $1,500.00
| Professional | | $519.54 | $519.54 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.60 / $319.60 / $319.60
| Professional | | $319.60 | $319.60 | $319.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.58 / $724.25 / $1,975.46
| Facility | | $61.58 | $724.25 | $1,975.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $110.54 / $139.00
| Professional | | $109.45 | $110.54 | $139.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $519.54 / $653.23
| Facility | | $400.00 | $519.54 | $653.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.00 / $1,120.00 / $1,120.00
| Professional | | $1,120.00 | $1,120.00 | $1,120.00 |