- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $363.08 / $602.56
| Professional | | $41.69 | $363.08 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $57.54 / $91.20
| Professional | | $38.90 | $57.54 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $47.86 / $74.13
| Professional | | $36.31 | $47.86 | $74.13 |