- 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
- $29.50 / $29.50 / $37.43
| Professional | | $29.50 | $29.50 | $37.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.39 / $1,107.46 / $1,905.65
| Facility | | $593.39 | $1,107.46 | $1,905.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $13.20 / $13.20
| Professional | | $13.20 | $13.20 | $13.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.00 / $513.00 / $1,226.00
| Facility | | $194.00 | $513.00 | $1,226.00 |