- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $870.96
| Professional | | $630.96 | $870.96 | $870.96 |
- 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
- $645.65 / $1,000.00 / $1,778.28
| Professional | | $645.65 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $870.96 / $954.99
| Facility | | $89.13 | $870.96 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.48 / $371.54 / $758.58
| Facility | | $52.48 | $371.54 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $549.54 / $831.76
| Professional | | $380.19 | $549.54 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $6,760.83 / $6,760.83
| Facility | | $812.83 | $6,760.83 | $6,760.83 |