- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $707.95 / $1,096.48
| Professional | | $457.09 | $707.95 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,202.26
| Facility | | $1,000.00 | $1,000.00 | $1,202.26 |
- 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
- $1,096.48 / $1,122.02 / $2,187.76
| Facility | | $1,096.48 | $1,122.02 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,122.02 / $2,187.76
| Professional | | $1,096.48 | $1,122.02 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $630.96 / $1,202.26
| Facility | | $190.55 | $630.96 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,096.48
| Professional | | $1,000.00 | $1,000.00 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,122.02
| Professional | | $707.95 | $812.83 | $1,122.02 |