- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.70 / $113.08 / $2,000.00
| Facility | | $55.70 | $113.08 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.48 / $112.42 / $137.28
| Professional | | $53.48 | $112.42 | $137.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.18 / $161.37 / $275.20
| Professional | | $107.18 | $161.37 | $275.20 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $160.77 / $268.32 / $411.08
| Professional | 50 | $160.77 | $268.32 | $411.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.96 / $172.13 / $349.39
| Professional | | $93.96 | $172.13 | $349.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.70 / $113.08 / $190.08
| Facility | | $55.70 | $113.08 | $190.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.80 / $223.48 / $295.77
| Professional | | $124.80 | $223.48 | $295.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.13 / $218.75 / $295.77
| Professional | | $115.13 | $218.75 | $295.77 |