- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.68 / $100.68 / $1,150.00
| Facility | | $100.68 | $100.68 | $1,150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.65 / $150.00 / $191.18
| Professional | | $99.65 | $150.00 | $191.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.53 / $104.53 / $104.53
| Professional | | $104.53 | $104.53 | $104.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.14 / $307.14 / $307.14
| Facility | | $307.14 | $307.14 | $307.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.53 / $88.53 / $88.53
| Professional | | $88.53 | $88.53 | $88.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.50 / $50.00 / $80.00
| Professional | | $42.50 | $50.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.79 / $178.46 / $229.37
| Professional | | $104.79 | $178.46 | $229.37 |