- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $954.99 / $1,000.00
| Facility | | $30.20 | $954.99 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $1,122.02
| Professional | | $30.20 | $57.54 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.31 / $3.72 / $7.94
| Professional | | $3.31 | $3.72 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $575.44 / $794.33
| Professional | | $371.54 | $575.44 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $630.96 / $691.83
| Professional | | $380.19 | $630.96 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $67.61 / $100.00
| Professional | | $45.71 | $67.61 | $100.00 |