- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $512.86 / $891.25
| Professional | | $338.84 | $512.86 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $891.25
| Facility | | $575.44 | $575.44 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $758.58
| Professional | | $416.87 | $416.87 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $501.19 / $812.83
| Facility | | $288.40 | $501.19 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $380.19 / $588.84
| Professional | | $346.74 | $380.19 | $588.84 |