- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.04 / $570.38 / $2,000.00
| Facility | | $56.04 | $570.38 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.98 / $56.04 / $87.43
| Professional | | $53.98 | $56.04 | $87.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.73 / $118.37 / $141.91
| Professional | | $108.73 | $118.37 | $141.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.70 / $130.69 / $168.78
| Professional | | $80.70 | $130.69 | $168.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.04 / $78.26 / $168.12
| Facility | | $56.04 | $78.26 | $168.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.36 / $106.98 / $144.93
| Professional | | $68.36 | $106.98 | $144.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.36 / $106.98 / $144.93
| Professional | | $68.36 | $106.98 | $144.93 |