- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $794.33 / $1,318.26
| Professional | | $575.44 | $794.33 | $1,318.26 |
- 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
- $851.14 / $1,000.00 / $1,023.29
| Professional | | $851.14 | $1,000.00 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $537.03 / $812.83
| Facility | | $72.44 | $537.03 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $616.60 / $1,023.29
| Professional | | $407.38 | $616.60 | $1,023.29 |