- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.44 / $69.42 / $2,000.00
| Facility | | $43.44 | $69.42 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.44 / $80.01 / $117.78
| Professional | | $43.44 | $80.01 | $117.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.42 / $140.97 / $203.09
| Professional | | $89.42 | $140.97 | $203.09 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $134.13 / $182.10 / $304.56
| Professional | 50 | $134.13 | $182.10 | $304.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.30 / $136.08 / $213.65
| Professional | | $84.30 | $136.08 | $213.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.44 / $75.01 / $138.87
| Facility | | $43.44 | $75.01 | $138.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.20 / $153.66 / $236.42
| Professional | | $78.20 | $153.66 | $236.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.20 / $150.87 / $221.97
| Professional | | $78.20 | $150.87 | $221.97 |