- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $208.93 / $1,348.96
| Facility | | $102.33 | $208.93 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $102.33 / $123.03
| Professional | | $100.00 | $102.33 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $67.61 / $275.42
| Professional | | $7.94 | $67.61 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Facility | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |