- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.69 / $74.26 / $1,526.28
| Facility | | $6.69 | $74.26 | $1,526.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.56 / $77.84 / $3,500.00
| Professional | | $73.56 | $77.84 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.88 / $312.79 / $463.53
| Facility | | $116.88 | $312.79 | $463.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.78 / $101.78 / $101.78
| Professional | | $101.78 | $101.78 | $101.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.50 / $70.02 / $81.09
| Facility | | $35.50 | $70.02 | $81.09 |