- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,250.00
| Facility | | $960.00 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,892.47 / $2,120.77
| Professional | | $1,000.00 | $1,892.47 | $2,120.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,195.78 / $7,518.88 / $10,115.29
| Facility | | $6,195.78 | $7,518.88 | $10,115.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.00 / $3,384.00 / $5,251.00
| Facility | | $1,092.00 | $3,384.00 | $5,251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.67 / $1,632.69 / $2,246.69
| Professional | | $761.67 | $1,632.69 | $2,246.69 |