- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $162.18 / $302.00
| Facility | | $123.03 | $162.18 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $676.08 / $2,630.27
| Facility | | $257.04 | $676.08 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $154.88 / $549.54
| Professional | | $109.65 | $154.88 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |