- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.92 / $3,457.50 / $7,278.00
| Facility | | $292.92 | $3,457.50 | $7,278.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.13 / $2,419.44 / $7,190.25
| Professional | | $328.13 | $2,419.44 | $7,190.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.13 / $105.13 / $105.13
| Professional | | $105.13 | $105.13 | $105.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $900.00 / $900.00
| Facility | | $900.00 | $900.00 | $900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.00 / $2,376.00 / $4,102.00
| Facility | | $554.00 | $2,376.00 | $4,102.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Facility | | $55.00 | $55.00 | $55.00 |