- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $962.52 / $9,062.00
| Facility | | $47.86 | $962.52 | $9,062.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $1,456.81
| Professional | | $47.86 | $47.86 | $1,456.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.51 / $164.51 / $164.51
| Facility | | $164.51 | $164.51 | $164.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.60 / $7.60 / $7.60
| Professional | | $7.60 | $7.60 | $7.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $101.46 / $163.61
| Facility | | $47.86 | $101.46 | $163.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.00 / $1,221.00 / $3,585.00
| Facility | | $225.00 | $1,221.00 | $3,585.00 |