- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $3,235.94 / $23,442.29
| Facility | | $524.81 | $3,235.94 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $229.09 / $575.44
| Professional | | $204.17 | $229.09 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $263.03 / $380.19
| Professional | | $190.55 | $263.03 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $229.09 / $363.08
| Professional | | $165.96 | $229.09 | $363.08 |