- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $660.69
| Professional | | $512.86 | $645.65 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $2,089.30
| Facility | | $676.08 | $912.01 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $2,089.30
| Professional | | $676.08 | $912.01 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,000.00 / $1,513.56
| Facility | | $602.56 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $616.60 / $1,000.00
| Professional | | $79.43 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $676.08
| Professional | | $288.40 | $288.40 | $676.08 |