- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $758.42 / $802.90
| Facility | | $100.00 | $758.42 | $802.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $350.00 / $350.00
| Professional | | $350.00 | $350.00 | $350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $5,023.62 / $5,023.62
| Professional | | $0.02 | $5,023.62 | $5,023.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.25 / $245.67 / $300.27
| Facility | | $184.25 | $245.67 | $300.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.08 / $257.95 / $331.66
| Professional | | $191.08 | $257.95 | $331.66 |