- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $4,365.16 / $7,244.36
| Facility | | $190.55 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $323.59 / $524.81
| Professional | | $204.17 | $323.59 | $524.81 |
- 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
- $5,370.32 / $5,370.32 / $6,165.95
| Facility | | $5,370.32 | $5,370.32 | $6,165.95 |
- 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
- $199.53 / $239.88 / $380.19
| Professional | | $199.53 | $239.88 | $380.19 |