- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.98 / $48.07 / $2,832.72
| Facility | | $0.98 | $48.07 | $2,832.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.47 / $581.78 / $7,857.04
| Professional | | $70.47 | $581.78 | $7,857.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.00 / $1,369.00 / $1,369.00
| Professional | | $1,369.00 | $1,369.00 | $1,369.00 |
- 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 / $37.00 / $41.00
| Facility | | $36.00 | $37.00 | $41.00 |