- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.00 / $1,100.00 / $2,250.00
| Facility | | $575.00 | $1,100.00 | $2,250.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.17 / $2,379.96 / $3,201.82
| Facility | | $1,961.17 | $2,379.96 | $3,201.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.00 / $780.00 / $780.00
| Professional | | $780.00 | $780.00 | $780.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,141.00 / $2,473.00
| Facility | | $375.00 | $1,141.00 | $2,473.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.03 / $128.03 / $191.37
| Professional | | $128.03 | $128.03 | $191.37 |