- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.08 / $277.83 / $1,400.00
| Facility | | $41.08 | $277.83 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.44 / $63.34 / $465.73
| Professional | | $36.44 | $63.34 | $465.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.35 / $49.06 / $53.45
| Facility | | $44.35 | $49.06 | $53.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.51 / $47.51 / $47.51
| Professional | | $47.51 | $47.51 | $47.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.12 / $71.12 / $71.12
| Facility | | $71.12 | $71.12 | $71.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.51 / $193.33 / $1,079.16
| Professional | | $47.51 | $193.33 | $1,079.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.55 / $1,472.55 / $1,472.55
| Facility | | $1,472.55 | $1,472.55 | $1,472.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.67 / $427.37 / $750.65
| Professional | | $278.67 | $427.37 | $750.65 |