- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $700.00 / $1,399.00 / $2,250.00
| Facility | | $700.00 | $1,399.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.06 / $182.62 / $206.54
| Professional | | $166.06 | $182.62 | $206.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.30 / $2,745.40 / $3,693.45
| Facility | | $2,262.30 | $2,745.40 | $3,693.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.00 / $3,129.00 / $5,251.00
| Facility | | $950.00 | $3,129.00 | $5,251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.75 / $221.20 / $336.80
| Professional | | $170.75 | $221.20 | $336.80 |