- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $1,230.27
| Professional | | $602.56 | $602.56 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,202.26
| Facility | | $1,000.00 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.71 / $389.05 / $954.99
| Facility | | $45.71 | $389.05 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $602.56 / $954.99
| Professional | | $436.52 | $602.56 | $954.99 |