- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Facility | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $1,000.00 / $1,000.00
| Professional | | $50.12 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $741.31 / $1,737.80
| Facility | | $524.81 | $741.31 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $10.00 / $10.00
| Professional | | $0.02 | $10.00 | $10.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $4,466.84
| Facility | | $64.57 | $64.57 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.58 / $1.82 / $1.86
| Professional | | $1.58 | $1.82 | $1.86 |