- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.00 / $2,447.00 / $5,150.00
| Facility | | $860.00 | $2,447.00 | $5,150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.80 / $1,395.28 / $1,395.28
| Professional | | $1,301.80 | $1,395.28 | $1,395.28 |
- 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
- $1,305.00 / $7,100.00 / $22,240.00
| Facility | | $1,305.00 | $7,100.00 | $22,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.82 / $1,629.41 / $2,791.36
| Professional | | $1,203.82 | $1,629.41 | $2,791.36 |