- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.90 / $727.27 / $4,801.77
| Facility | | $86.90 | $727.27 | $4,801.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.65 / $2,673.50 / $2,673.50
| Professional | | $34.65 | $2,673.50 | $2,673.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.64 / $44.61 / $88.09
| Facility | | $28.64 | $44.61 | $88.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.40 / $125.40 / $125.40
| Professional | | $125.40 | $125.40 | $125.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.90 / $727.27 / $4,801.77
| Facility | | $86.90 | $727.27 | $4,801.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.65 / $35.70 / $2,673.50
| Professional | | $34.65 | $35.70 | $2,673.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $75.00
| Professional | | $30.00 | $30.00 | $75.00 |