- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,576.00 / $8,400.00
| Facility | | $1,000.00 | $3,576.00 | $8,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.64 / $335.64 / $335.64
| Professional | | $335.64 | $335.64 | $335.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.64 / $1,295.32 / $4,297.72
| Facility | | $335.64 | $1,295.32 | $4,297.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.71 / $513.60 / $2,560.16
| Professional | | $370.71 | $513.60 | $2,560.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.00 / $1,760.00 / $3,790.62
| Facility | | $575.00 | $1,760.00 | $3,790.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.71 / $509.73 / $742.81
| Professional | | $370.71 | $509.73 | $742.81 |