- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.00 / $2,898.00 / $3,444.00
| Facility | | $988.00 | $2,898.00 | $3,444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.89 / $22.89 / $23.57
| Professional | | $22.89 | $22.89 | $23.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.17 / $64.48 / $82.08
| Professional | | $45.17 | $64.48 | $82.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.82 / $31.54 / $37.29
| Professional | | $27.82 | $31.54 | $37.29 |