- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.00 / $1,850.00 / $3,945.00
| Facility | | $455.00 | $1,850.00 | $3,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.68 / $191.58 / $218.40
| Professional | | $180.68 | $191.58 | $218.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.58 / $1,307.08 / $2,303.34
| Facility | | $90.58 | $1,307.08 | $2,303.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.00 / $1,429.00 / $4,010.00
| Facility | | $470.00 | $1,429.00 | $4,010.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.87 / $235.42 / $407.26
| Professional | | $168.87 | $235.42 | $407.26 |