- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $850.00 / $4,876.25
| Professional | | $500.00 | $850.00 | $4,876.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,269.29 / $1,269.29 / $1,269.29
| Facility | | $1,269.29 | $1,269.29 | $1,269.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,703.64 / $1,703.64 / $1,703.64
| Professional | | $1,703.64 | $1,703.64 | $1,703.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,269.29 / $1,269.29 / $1,269.29
| Facility | | $1,269.29 | $1,269.29 | $1,269.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.93 / $492.93 / $1,703.64
| Professional | | $492.93 | $492.93 | $1,703.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.51 / $758.36 / $1,752.11
| Professional | | $318.51 | $758.36 | $1,752.11 |