- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.40 / $147.40 / $7,776.50
| Facility | | $147.40 | $147.40 | $7,776.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.65 / $147.40 / $176.88
| Professional | | $34.65 | $147.40 | $176.88 |
- 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
- $125.40 / $125.40 / $125.40
| Professional | | $125.40 | $125.40 | $125.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,651.18 / $3,848.24 / $7,667.78
| Facility | | $3,651.18 | $3,848.24 | $7,667.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |