- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.43 / $3,084.00 / $4,707.00
| Facility | | $37.43 | $3,084.00 | $4,707.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.50 / $37.43 / $323.98
| Professional | | $29.50 | $37.43 | $323.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $13.20 / $13.20
| Professional | | $13.20 | $13.20 | $13.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $873.66 / $1,190.82 / $1,735.36
| Facility | | $873.66 | $1,190.82 | $1,735.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,556.00 / $4,495.00
| Facility | | $1,078.00 | $1,556.00 | $4,495.00 |