- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.73 / $382.10 / $6,907.00
| Facility | | $251.73 | $382.10 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.95 / $128.84 / $155.52
| Professional | | $97.95 | $128.84 | $155.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.48 / $153.66 / $219.31
| Professional | | $106.48 | $153.66 | $219.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,132.00 / $6,132.00 / $6,132.00
| Facility | | $6,132.00 | $6,132.00 | $6,132.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Facility | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.60 / $178.81 / $351.60
| Professional | | $143.60 | $178.81 | $351.60 |