- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,362.00 / $3,817.00 / $7,182.80
| Facility | | $1,362.00 | $3,817.00 | $7,182.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.88 / $454.88 / $2,418.42
| Professional | | $454.88 | $454.88 | $2,418.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.03 / $4,429.60 / $8,135.37
| Facility | | $699.03 | $4,429.60 | $8,135.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $2,500.00
| Facility | | $500.00 | $500.00 | $2,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.00 / $1,550.00 / $2,665.00
| Facility | | $175.00 | $1,550.00 | $2,665.00 |