- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $1,148.15 / $1,230.27
| Facility | | $30.20 | $1,148.15 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $1,174.90
| Professional | | $30.20 | $57.54 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $3.98 / $7.94
| Professional | | $3.72 | $3.98 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $724.44 / $1,000.00
| Professional | | $457.09 | $724.44 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $776.25 / $831.76
| Professional | | $457.09 | $776.25 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $67.61 / $100.00
| Professional | | $45.71 | $67.61 | $100.00 |