- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.46 / $2,222.63 / $3,543.71
| Facility | | $137.46 | $2,222.63 | $3,543.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.58 / $137.46 / $458.09
| Professional | | $52.58 | $137.46 | $458.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.86 / $99.52 / $585.45
| Professional | | $55.86 | $99.52 | $585.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $852.58 / $852.58 / $852.58
| Facility | | $852.58 | $852.58 | $852.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $5,000.00 / $5,000.00
| Facility | | $5,000.00 | $5,000.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.07 / $527.04 / $850.73
| Professional | | $364.07 | $527.04 | $850.73 |