- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,380.38
| Facility | | $1,000.00 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $676.08 / $1,000.00
| Professional | | $467.74 | $676.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,584.89
| Professional | | $1,202.26 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,023.29 / $1,479.11
| Facility | | $512.86 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $794.33
| Facility | | $707.95 | $707.95 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $467.74 / $794.33
| Professional | | $331.13 | $467.74 | $794.33 |