- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.54 / $516.33 / $2,663.96
| Facility | | $30.54 | $516.33 | $2,663.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.46 / $30.54 / $42.00
| Professional | | $12.46 | $30.54 | $42.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.08 / $17.75 / $17.75
| Professional | | $15.08 | $17.75 | $17.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.94 / $150.94 / $150.94
| Professional | | $150.94 | $150.94 | $150.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,410.00
| Professional | | $2,500.00 | $3,000.00 | $4,410.00 |