- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $70.79 / $123.03
| Facility | | $47.86 | $70.79 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $47.86 / $102.33
| Professional | | $30.20 | $47.86 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.02 / $2,344.23 / $3,981.07
| Facility | | $38.02 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $61.66 / $100.00
| Professional | | $39.81 | $61.66 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $478.63 / $478.63
| Professional | | $223.87 | $478.63 | $478.63 |