- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,380.38
| Professional | | $776.25 | $1,000.00 | $1,380.38 |
- 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
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $512.86 / $512.86
| Professional | | $125.89 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $776.25 / $1,071.52
| Professional | | $501.19 | $776.25 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $389.05 / $912.01
| Facility | | $58.88 | $389.05 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $630.96 / $977.24
| Professional | | $501.19 | $630.96 | $977.24 |