- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $107.15 / $138.04
| Facility | | $91.20 | $107.15 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $107.15 / $154.88
| Professional | | $91.20 | $107.15 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $5,011.87
| Facility | | $1,819.70 | $3,548.13 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $141.25 / $239.88
| Professional | | $102.33 | $141.25 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $91.20 / $53,703.18
| Facility | | $72.44 | $91.20 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $39.81 / $186.21
| Professional | | $30.20 | $39.81 | $186.21 |