- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $270.89 / $2,050.17
| Facility | | $108.36 | $270.89 | $2,050.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.98 / $108.36 / $109.63
| Professional | | $101.98 | $108.36 | $109.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Facility | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.76 / $109.63 / $138.69
| Facility | | $97.76 | $109.63 | $138.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,900.00
| Professional | | $30.00 | $30.00 | $3,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.24 / $106.24 / $148.74
| Professional | | $106.24 | $106.24 | $148.74 |