- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $436.52
| Facility | | $30.20 | $30.20 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $1,000.00
| Professional | | $30.20 | $44.67 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $676.08 / $1,258.93
| Professional | | $436.52 | $676.08 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $2,570.40 / $5,623.41
| Facility | | $50.12 | $2,570.40 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $602.56 / $1,000.00
| Professional | | $190.55 | $602.56 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $58.88 / $79.43
| Professional | | $42.66 | $58.88 | $79.43 |