- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.22 / $37.22 / $1,600.80
| Facility | | $37.22 | $37.22 | $1,600.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.22 / $37.22 / $37.67
| Professional | | $37.22 | $37.22 | $37.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.41 / $60.35 / $70.64
| Professional | | $28.41 | $60.35 | $70.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.51 / $400.00 / $2,490.86
| Facility | | $35.51 | $400.00 | $2,490.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.25 / $51.93 / $433.89
| Professional | | $37.25 | $51.93 | $433.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $610.00 / $1,883.00
| Facility | | $100.00 | $610.00 | $1,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.25 / $50.53 / $73.70
| Professional | | $37.25 | $50.53 | $73.70 |