- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.61 / $2,678.00 / $7,602.00
| Facility | | $655.61 | $2,678.00 | $7,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $655.61
| Professional | | $655.61 | $655.61 | $655.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $2,161.00 / $3,047.00
| Facility | | $1,275.00 | $2,161.00 | $3,047.00 |
- 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
- $1,128.00 / $2,297.00 / $4,326.00
| Facility | | $1,128.00 | $2,297.00 | $4,326.00 |