- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.28 / $63.00 / $63.00
| Facility | | $52.28 | $63.00 | $63.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.00 / $50.50 / $63.00
| Professional | | $38.00 | $50.50 | $63.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.03 / $2,840.63 / $3,333.00
| Facility | | $30.03 | $2,840.63 | $3,333.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.83 / $52.28 / $63.76
| Professional | | $33.83 | $52.28 | $63.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.63 / $30.00 / $55.00
| Professional | | $2.63 | $30.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.00 / $56.00 / $74.00
| Professional | | $38.00 | $56.00 | $74.00 |