- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.44 / $204.38 / $2,000.00
| Facility | | $52.44 | $204.38 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.52 / $142.27 / $226.58
| Professional | | $47.52 | $142.27 | $226.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.26 / $301.58 / $519.90
| Professional | | $101.26 | $301.58 | $519.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.56 / $162.99 / $649.79
| Professional | | $76.56 | $162.99 | $649.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.44 / $204.38 / $352.69
| Facility | | $52.44 | $204.38 | $352.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.30 / $333.84 / $791.94
| Professional | | $200.30 | $333.84 | $791.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.30 / $316.07 / $454.94
| Professional | | $200.30 | $316.07 | $454.94 |