- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.20 / $340.87 / $496.00
| Facility | | $247.20 | $340.87 | $496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.00 / $160.87 / $5,000.00
| Professional | | $27.00 | $160.87 | $5,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.52 / $22.99 / $91.04
| Facility | | $12.52 | $22.99 | $91.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.80 / $14.94 / $3,744.36
| Professional | | $4.80 | $14.94 | $3,744.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.00 / $800.00 / $800.00
| Professional | | $800.00 | $800.00 | $800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $14.00 / $14.00
| Professional | | $14.00 | $14.00 | $14.00 |