- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.00 / $2,771.00 / $6,305.00
| Facility | | $1,170.00 | $2,771.00 | $6,305.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.00 / $1,686.00 / $4,573.00
| Professional | | $612.00 | $1,686.00 | $4,573.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.56 / $614.42 / $1,076.63
| Facility | | $164.56 | $614.42 | $1,076.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $247.29 / $287.47
| Professional | | $216.38 | $247.29 | $287.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |