- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.48 / $1,328.51 / $6,907.00
| Facility | | $914.48 | $1,328.51 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.75 / $364.58 / $516.92
| Professional | | $280.75 | $364.58 | $516.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.22 / $445.82 / $718.24
| Professional | | $308.22 | $445.82 | $718.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.43 / $513.91 / $1,044.82
| Professional | | $386.43 | $513.91 | $1,044.82 |