- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,071.52 / $1,071.52
| Professional | | $1,000.00 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $3,715.35
| Facility | | $1,698.24 | $2,137.96 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $1,318.26
| Professional | | $1,230.27 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,445.44
| Facility | | $1,122.02 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,348.96
| Professional | | $954.99 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,479.11 / $1,479.11
| Professional | | $660.69 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,071.52 / $1,071.52
| Professional | | $1,000.00 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $977.24 / $1,288.25
| Facility | | $125.89 | $977.24 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,445.44 / $1,995.26
| Professional | | $660.69 | $1,445.44 | $1,995.26 |