- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $239.88 / $331.13
| Facility | | $213.80 | $239.88 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,122.02 / $2,884.03
| Facility | | $630.96 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,047.13 / $1,318.26
| Facility | | $977.24 | $1,047.13 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,023.29 / $1,412.54
| Facility | | $1,000.00 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $33.11 / $33.11
| Professional | | $33.11 | $33.11 | $33.11 |