- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.30 / $1,821.00 / $9,477.00
| Facility | | $24.30 | $1,821.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.00 / $1,846.00 / $1,846.00
| Professional | | $1,846.00 | $1,846.00 | $1,846.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.69 / $23.69 / $23.69
| Facility | | $23.69 | $23.69 | $23.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.72 / $20.81 / $20.81
| Professional | | $15.72 | $20.81 | $20.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.82 / $37.93 / $52.72
| Facility | | $14.82 | $37.93 | $52.72 |