- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.33 / $1,181.00 / $3,109.00
| Facility | | $104.33 | $1,181.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.33 / $165.44 / $317.61
| Professional | | $104.33 | $165.44 | $317.61 |
- 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
- $166.85 / $243.60 / $400.34
| Professional | | $166.85 | $243.60 | $400.34 |