- 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
- $53.70 / $186.21 / $316.23
| Professional | | $53.70 | $186.21 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $257.04
| Professional | | $186.21 | $186.21 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $213.80 / $275.42
| Professional | | $117.49 | $213.80 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $213.80 / $309.03
| Professional | | $151.36 | $213.80 | $309.03 |