- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $3,311.31 / $6,456.54
| Facility | | $239.88 | $3,311.31 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $371.54
| Professional | | $239.88 | $239.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $5.01 / $5.01
| Professional | | $3.02 | $5.01 | $5.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $2,187.76
| Professional | | $281.84 | $281.84 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |