- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $2,884.03
| Facility | | $1,000.00 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $229.09 / $407.38
| Professional | | $186.21 | $229.09 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $194.98
| Professional | | $138.04 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $269.15 / $331.13
| Professional | | $234.42 | $269.15 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $257.04 / $549.54
| Professional | | $138.04 | $257.04 | $549.54 |