- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.84 / $53.84 / $8,500.00
| Facility | | $53.84 | $53.84 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.07 / $47.23 / $53.84
| Professional | | $40.07 | $47.23 | $53.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.10 / $53.84 / $161.52
| Facility | | $17.10 | $53.84 | $161.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.00 / $20.93 / $322.39
| Professional | | $13.00 | $20.93 | $322.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.55 / $20.30 / $33.89
| Professional | | $12.55 | $20.30 | $33.89 |