- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $120.23
| Facility | | $100.00 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.79 / $89.13 / $223.87
| Facility | | $70.79 | $89.13 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $95.50 / $114.82
| Professional | | $42.66 | $95.50 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $151.36
| Facility | | $102.33 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $54.95 / $63.10
| Professional | | $34.67 | $54.95 | $63.10 |