- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.00 / $1,223.00 / $2,250.00
| Facility | | $750.00 | $1,223.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.41 / $1,162.01 / $1,314.48
| Professional | | $1,115.41 | $1,162.01 | $1,314.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,715.59 / $6,936.13 / $9,331.32
| Facility | | $5,715.59 | $6,936.13 | $9,331.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.82 / $1,485.09 / $2,227.83
| Professional | | $1,113.82 | $1,485.09 | $2,227.83 |