- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $1,520.00 / $3,728.00
| Facility | | $400.00 | $1,520.00 | $3,728.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.11 / $138.88 / $158.33
| Professional | | $136.11 | $138.88 | $158.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.70 / $145.93 / $412.07
| Facility | | $67.70 | $145.93 | $412.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.00 / $513.00 / $1,226.00
| Facility | | $194.00 | $513.00 | $1,226.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.72 / $154.10 / $258.31
| Professional | | $118.72 | $154.10 | $258.31 |