- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $1,318.26
| Professional | | $489.78 | $812.83 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $1,230.27 / $2,137.96
| Professional | | $123.03 | $1,230.27 | $2,137.96 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $1,000.00 / $1,000.00
| Professional | | $501.19 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $354.81 / $851.14
| Facility | | $58.88 | $354.81 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $831.76 / $1,621.81
| Professional | | $489.78 | $831.76 | $1,621.81 |