- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $43.64 / $43.64
| Facility | | $30.32 | $43.64 | $43.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.62 / $1,060.26
| Professional | | $30.32 | $30.62 | $1,060.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.60 / $502.71 / $1,738.43
| Facility | | $136.60 | $502.71 | $1,738.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.06 / $80.06 / $80.06
| Professional | | $80.06 | $80.06 | $80.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Facility | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Professional | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $327.13
| Facility | | $30.32 | $30.32 | $327.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Professional | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Professional | | $30.32 | $30.32 | $30.32 |