- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.32 / $36.32 / $753.00
| Facility | | $36.32 | $36.32 | $753.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.32 / $53.57 / $73.09
| Professional | | $36.32 | $53.57 | $73.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,262.04 / $3,262.04 / $4,042.19
| Facility | | $3,262.04 | $3,262.04 | $4,042.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.75 / $67.94 / $69.98
| Professional | | $57.75 | $67.94 | $69.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $108.00 / $158.00
| Professional | | $15.00 | $108.00 | $158.00 |