- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,202.26
| Professional | | $758.58 | $954.99 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.50 / $95.50 / $213.80
| Facility | | $95.50 | $95.50 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $95.50 / $95.50
| Professional | | $72.44 | $95.50 | $95.50 |
- 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
- $831.76 / $1,000.00 / $1,000.00
| Professional | | $831.76 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $776.25 / $1,047.13
| Facility | | $100.00 | $776.25 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,071.52 / $1,380.38
| Professional | | $575.44 | $1,071.52 | $1,380.38 |