- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.65 / $56.23 / $3,981.07
| Facility | | $43.65 | $56.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $602.56
| Professional | | $43.65 | $43.65 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $208.93
| Professional | | $100.00 | $120.23 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.20 / $1.20 / $1.20
| Professional | | $1.20 | $1.20 | $1.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.20 / $1.20 / $1.20
| Professional | | $1.20 | $1.20 | $1.20 |