- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.43 / $1,413.72 / $2,000.00
| Facility | | $43.43 | $1,413.72 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.89 / $94.15 / $159.44
| Professional | | $38.89 | $94.15 | $159.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.51 / $162.18 / $246.80
| Professional | | $83.51 | $162.18 | $246.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.53 / $126.59 / $303.80
| Professional | | $60.53 | $126.59 | $303.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.43 / $110.19 / $330.57
| Facility | | $43.43 | $110.19 | $330.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.24 / $212.30 / $288.35
| Professional | | $112.24 | $212.30 | $288.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.24 / $226.12 / $288.35
| Professional | | $112.24 | $226.12 | $288.35 |