- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.00 / $1,438.00 / $2,217.00
| Facility | | $707.00 | $1,438.00 | $2,217.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Facility | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Facility | | $55.00 | $55.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.16 / $2,117.16 / $2,187.02
| Professional | | $2,117.16 | $2,117.16 | $2,187.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.00 / $808.00 / $2,577.00
| Facility | | $294.00 | $808.00 | $2,577.00 |