- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $1,348.96
| Facility | | $1,000.00 | $1,148.15 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $478.63 / $1,348.96
| Professional | | $131.83 | $478.63 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $331.13 / $1,258.93
| Professional | | $138.04 | $331.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $288.40 / $1,479.11
| Professional | | $194.98 | $288.40 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $512.86 / $1,479.11
| Professional | | $169.82 | $512.86 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $1,348.96
| Facility | | $1,000.00 | $1,148.15 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $489.78 / $2,041.74
| Professional | | $151.36 | $489.78 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $380.19 / $1,479.11
| Professional | | $186.21 | $380.19 | $1,479.11 |