- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.91 / $1,268.00 / $2,250.00
| Facility | | $58.91 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.22 / $58.91 / $58.91
| Professional | | $36.22 | $58.91 | $58.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.60 / $88.00 / $103.84
| Professional | | $61.60 | $88.00 | $103.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.82 / $54.90 / $143.26
| Professional | | $36.82 | $54.90 | $143.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.56 / $44.39 / $66.63
| Professional | | $32.56 | $44.39 | $66.63 |