- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,476.94 / $3,155.56 / $4,575.56
| Professional | | $1,476.94 | $3,155.56 | $4,575.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,583.58 / $3,203.85 / $8,778.54
| Facility | | $1,583.58 | $3,203.85 | $8,778.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.00 / $1,005.05 / $1,343.58
| Professional | | $573.00 | $1,005.05 | $1,343.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.35 / $3,084.63 / $6,175.34
| Professional | | $1,765.35 | $3,084.63 | $6,175.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.53 / $1,895.49 / $5,320.35
| Professional | | $831.53 | $1,895.49 | $5,320.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.24 / $1,171.76 / $1,491.34
| Professional | | $1,065.24 | $1,171.76 | $1,491.34 |