- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.98 / $36.74 / $70.63
| Facility | | $0.98 | $36.74 | $70.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.85 / $4,686.57 / $6,722.84
| Professional | | $208.85 | $4,686.57 | $6,722.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.00 / $2,675.00 / $2,675.00
| Professional | | $2,675.00 | $2,675.00 | $2,675.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $507.00 / $641.21
| Facility | | $507.00 | $507.00 | $641.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.00 / $36.00 / $41.00
| Facility | | $36.00 | $36.00 | $41.00 |