- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.04 / $306.83 / $306.83
| Facility | | $143.04 | $306.83 | $306.83 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $28.61 / $61.37 / $153.47
| Facility | 53 | $28.61 | $61.37 | $153.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.83 / $410.50 / $895.65
| Facility | | $185.83 | $410.50 | $895.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $379.57 / $670.35 / $1,002.19
| Facility | | $379.57 | $670.35 | $1,002.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.70 / $420.48 / $601.57
| Professional | | $255.70 | $420.48 | $601.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |