- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.73 / $5,549.00 / $11,100.08
| Facility | | $101.73 | $5,549.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $49.60
| Professional | | $40.00 | $40.00 | $49.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.49 / $54.94 / $74.59
| Facility | | $35.49 | $54.94 | $74.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.61 / $107.61 / $107.61
| Professional | | $107.61 | $107.61 | $107.61 |