- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.45 / $1,821.00 / $9,477.00
| Facility | | $116.45 | $1,821.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.45 / $186.01 / $226.02
| Professional | | $116.45 | $186.01 | $226.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $726.58 / $726.58 / $726.58
| Facility | | $726.58 | $726.58 | $726.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.00 / $811.00 / $1,574.00
| Facility | | $330.00 | $811.00 | $1,574.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.94 / $266.49 / $420.44
| Professional | | $188.94 | $266.49 | $420.44 |