- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $309.03 / $380.19
| Facility | | $100.00 | $309.03 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $104.71
| Professional | | $100.00 | $100.00 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $323.59
| Professional | | $138.04 | $154.88 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $100.00 / $100.00
| Facility | | $93.33 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $85.11 / $100.00
| Professional | | $85.11 | $85.11 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $162.18
| Professional | | $100.00 | $100.00 | $162.18 |