- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.42 / $112.36 / $2,500.00
| Facility | | $56.42 | $112.36 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.46 / $100.36 / $144.34
| Professional | | $53.46 | $100.36 | $144.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.92 / $189.13 / $276.49
| Professional | | $101.92 | $189.13 | $276.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.39 / $164.85 / $341.78
| Professional | | $84.39 | $164.85 | $341.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.42 / $112.36 / $188.59
| Facility | | $56.42 | $112.36 | $188.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.60 / $218.77 / $420.70
| Professional | | $123.60 | $218.77 | $420.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.40 / $206.62 / $251.68
| Professional | | $114.40 | $206.62 | $251.68 |