- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.02 / $3,038.00 / $4,387.00
| Facility | | $104.02 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.02 / $104.02 / $104.02
| Professional | | $104.02 | $104.02 | $104.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,435.37 / $4,418.50 / $6,439.02
| Facility | | $3,435.37 | $4,418.50 | $6,439.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $3,613.00 / $7,048.00
| Facility | | $1,981.00 | $3,613.00 | $7,048.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $140.80 / $160.00
| Professional | | $108.80 | $140.80 | $160.00 |