- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,000.00 / $1,096.48
| Facility | | $537.03 | $1,000.00 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $512.86 / $1,000.00
| Professional | | $407.38 | $512.86 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Facility | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Professional | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $371.54 / $407.38
| Facility | | $354.81 | $371.54 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $776.25
| Professional | | $616.60 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $645.65
| Facility | | $489.78 | $489.78 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $295.12 / $1,202.26
| Professional | | $229.09 | $295.12 | $1,202.26 |