- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,047.13 / $1,047.13
| Professional | | $1,000.00 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $1,230.27
| Professional | | $363.08 | $363.08 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $1,819.70
| Professional | | $1,737.80 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $616.60 / $1,148.15
| Facility | | $81.28 | $616.60 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,202.26 / $1,621.81
| Professional | | $645.65 | $1,202.26 | $1,621.81 |