- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.60 / $538.27 / $1,003.32
| Facility | | $303.60 | $538.27 | $1,003.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,499.07 / $4,982.56 / $10,706.74
| Facility | | $2,499.07 | $4,982.56 | $10,706.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.84 / $532.84 / $532.84
| Facility | | $532.84 | $532.84 | $532.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.75 / $535.10 / $1,994.13
| Professional | | $341.75 | $535.10 | $1,994.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |