- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.54 / $906.54 / $906.54
| Professional | | $906.54 | $906.54 | $906.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.19 / $224.52 / $420.48
| Professional | | $168.19 | $224.52 | $420.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.39 / $510.39 / $611.51
| Professional | | $510.39 | $510.39 | $611.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.19 / $224.52 / $420.48
| Professional | | $168.19 | $224.52 | $420.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.10 / $224.52 / $420.48
| Professional | | $187.10 | $224.52 | $420.48 |