- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $3,925.53
| Facility | | $30.32 | $30.32 | $3,925.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $33.69
| Professional | | $30.32 | $30.32 | $33.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.85 / $6,283.58 / $8,453.43
| Facility | | $5,177.85 | $6,283.58 | $8,453.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $329.74
| Professional | | $30.32 | $30.32 | $329.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Facility | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Professional | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $32.14
| Professional | | $30.32 | $30.32 | $32.14 |