- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $4,880.68
| Professional | | $500.00 | $500.00 | $4,880.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.05 / $759.05 / $759.05
| Professional | | $759.05 | $759.05 | $759.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.45 / $1,270.45 / $1,270.45
| Facility | | $1,270.45 | $1,270.45 | $1,270.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.26 / $1,090.32 / $1,705.27
| Professional | | $872.26 | $1,090.32 | $1,705.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.45 / $1,270.45 / $1,270.45
| Facility | | $1,270.45 | $1,270.45 | $1,270.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.38 / $872.26 / $1,705.27
| Professional | | $493.38 | $872.26 | $1,705.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.55 / $481.40 / $1,753.71
| Professional | | $331.55 | $481.40 | $1,753.71 |