- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,071.52 / $4,073.80
| Facility | | $707.95 | $1,071.52 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $416.87 / $1,122.02
| Professional | | $269.15 | $416.87 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $436.52 / $724.44
| Professional | | $295.12 | $436.52 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $389.05 / $724.44
| Professional | | $245.47 | $389.05 | $724.44 |