- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $2,707.84 / $3,020.55
| Facility | | $118.61 | $2,707.84 | $3,020.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $152.28
| Professional | | $118.61 | $118.61 | $152.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $8.01
| Professional | | $0.02 | $0.02 | $8.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $125.73 / $200.45
| Facility | | $118.61 | $125.73 | $200.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |