- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $2,749.27 / $5,432.00
| Facility | | $900.00 | $2,749.27 | $5,432.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.53 / $2,411.64 / $2,749.27
| Professional | | $1,965.53 | $2,411.64 | $2,749.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $6,034.00 / $13,506.00
| Facility | | $1,200.00 | $6,034.00 | $13,506.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.39 / $2,283.71 / $4,335.77
| Professional | | $1,449.39 | $2,283.71 | $4,335.77 |