- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.31 / $500.00 / $765.00
| Facility | | $104.31 | $500.00 | $765.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.84 / $137.40 / $275.00
| Professional | | $112.84 | $137.40 | $275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.28 / $188.44 / $253.52
| Facility | | $155.28 | $188.44 | $253.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.26 / $380.00 / $3,138.00
| Facility | | $103.26 | $380.00 | $3,138.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.81 / $108.00 / $314.95
| Professional | | $75.81 | $108.00 | $314.95 |