- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.00 / $2,898.00 / $3,444.00
| Facility | | $988.00 | $2,898.00 | $3,444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.00 / $8.32 / $53.77
| Professional | | $8.00 | $8.32 | $53.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.46 / $93.23 / $108.77
| Professional | | $85.46 | $93.23 | $108.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.97 / $32.03 / $32.18
| Professional | | $18.97 | $32.03 | $32.18 |