- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $549.54
| Facility | | $39.81 | $57.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $602.56
| Professional | | $34.67 | $44.67 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $389.05 / $562.34
| Professional | | $331.13 | $389.05 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $436.52
| Professional | | $30.20 | $30.20 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $60.26
| Professional | | $39.81 | $50.12 | $60.26 |