- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.60 / $45.60 / $176.47
| Facility | | $45.60 | $45.60 | $176.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.60 / $45.60 / $57.00
| Professional | | $45.60 | $45.60 | $57.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.69 / $1,236.69 / $1,236.69
| Professional | | $1,236.69 | $1,236.69 | $1,236.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.47 / $2,800.00 / $2,800.00
| Professional | | $443.47 | $2,800.00 | $2,800.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.60 / $176.47 / $326.18
| Facility | | $45.60 | $176.47 | $326.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.60 / $45.60 / $57.00
| Professional | | $45.60 | $45.60 | $57.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.47 / $2,800.00 / $2,800.00
| Professional | | $443.47 | $2,800.00 | $2,800.00 |