- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.50 / $7,838.38 / $8,763.29
| Facility | | $367.50 | $7,838.38 | $8,763.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.50 / $367.50 / $367.50
| Professional | | $367.50 | $367.50 | $367.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $1,500.00
| Professional | | $60.00 | $85.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.50 / $367.50 / $2,000.00
| Facility | | $367.50 | $367.50 | $2,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.00 / $9,127.00 / $13,891.00
| Facility | | $790.00 | $9,127.00 | $13,891.00 |