- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.98 / $4,646.97 / $7,401.77
| Facility | | $0.98 | $4,646.97 | $7,401.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.50 / $540.00 / $2,100.00
| Professional | | $35.50 | $540.00 | $2,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.00 / $2,141.00 / $2,141.00
| Professional | | $2,141.00 | $2,141.00 | $2,141.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $507.00 / $641.21
| Facility | | $507.00 | $507.00 | $641.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.00 / $36.00 / $41.00
| Facility | | $36.00 | $36.00 | $41.00 |