- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.00 / $1,268.00 / $2,250.00
| Facility | | $320.00 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.20 / $320.00 / $358.64
| Professional | | $215.20 | $320.00 | $358.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,940.51 / $7,209.09 / $9,698.54
| Facility | | $5,940.51 | $7,209.09 | $9,698.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.00 / $3,384.00 / $5,251.00
| Facility | | $1,124.00 | $3,384.00 | $5,251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.83 / $266.58 / $426.04
| Professional | | $213.83 | $266.58 | $426.04 |