- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.26 / $161.07 / $2,000.00
| Facility | | $54.26 | $161.07 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.35 / $72.81 / $89.48
| Professional | | $51.35 | $72.81 | $89.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.12 / $143.81 / $199.58
| Professional | | $111.12 | $143.81 | $199.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.87 / $165.34 / $266.88
| Professional | | $105.87 | $165.34 | $266.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.26 / $104.31 / $326.74
| Facility | | $54.26 | $104.31 | $326.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.81 / $151.84 / $636.72
| Professional | | $84.81 | $151.84 | $636.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.90 / $135.35 / $216.15
| Professional | | $81.90 | $135.35 | $216.15 |