- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.00 / $936.14 / $1,248.19
| Facility | | $235.00 | $936.14 | $1,248.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $834.27 / $4,688.88 / $4,783.06
| Facility | | $834.27 | $4,688.88 | $4,783.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.72 / $187.72 / $187.72
| Professional | | $187.72 | $187.72 | $187.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.00 / $235.00 / $235.00
| Facility | | $235.00 | $235.00 | $235.00 |