- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.56 / $2,678.00 / $7,602.00
| Facility | | $287.56 | $2,678.00 | $7,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $287.56
| Professional | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.00 / $2,202.00 / $3,084.00
| Facility | | $1,270.00 | $2,202.00 | $3,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.71 / $911.71 / $911.71
| Professional | | $911.71 | $911.71 | $911.71 |
- 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
- $719.00 / $1,560.00 / $2,914.00
| Facility | | $719.00 | $1,560.00 | $2,914.00 |