- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $426.58 / $831.76
| Facility | | $123.03 | $426.58 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $138.04 / $190.55
| Professional | | $123.03 | $138.04 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $186.21 / $245.47
| Professional | | $173.78 | $186.21 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $426.58 / $1,000.00
| Facility | | $114.82 | $426.58 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $158.49 / $323.59
| Facility | | $131.83 | $158.49 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $173.78 / $208.93
| Facility | | $158.49 | $173.78 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $104.71 / $173.78
| Professional | | $74.13 | $104.71 | $173.78 |