- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.80 / $3,376.41 / $3,376.41
| Facility | | $988.80 | $3,376.41 | $3,376.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.74 / $38.59 / $2,673.50
| Professional | | $9.74 | $38.59 | $2,673.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.12 / $14.12 / $14.12
| Professional | | $14.12 | $14.12 | $14.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.40 / $125.40 / $125.40
| Professional | | $125.40 | $125.40 | $125.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $493.00
| Professional | | $100.00 | $200.00 | $493.00 |