- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $1,412.54 / $2,041.74
| Facility | | $323.59 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $588.84 / $1,412.54
| Professional | | $208.93 | $588.84 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $245.47
| Professional | | $186.21 | $186.21 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,318.26
| Professional | | $1,000.00 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $426.58 / $1,905.46
| Professional | | $281.84 | $426.58 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $851.14
| Facility | | $128.82 | $346.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $501.19 / $1,819.70
| Professional | | $208.93 | $501.19 | $1,819.70 |