- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,000.00 / $2,137.96
| Facility | | $316.23 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $524.81
| Professional | | $316.23 | $316.23 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $316.23 / $316.23
| Facility | | $158.49 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $309.03 / $707.95
| Professional | | $263.03 | $309.03 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $239.88 / $239.88
| Facility | | $173.78 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $416.87
| Facility | | $204.17 | $204.17 | $416.87 |