- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,348.96
| Professional | | $794.33 | $794.33 | $1,348.96 |
- 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
- $100.00 / $870.96 / $1,000.00
| Professional | | $100.00 | $870.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $2,187.76
| Professional | | $2,089.30 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $537.03 / $954.99
| Facility | | $72.44 | $537.03 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,000.00 / $1,380.38
| Professional | | $537.03 | $1,000.00 | $1,380.38 |