- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,250.00
| Facility | | $960.00 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,353.71 / $4,069.89 / $5,475.31
| Facility | | $3,353.71 | $4,069.89 | $5,475.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $1,102.00
| Professional | | $25.00 | $25.00 | $1,102.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $1,754.00 / $3,200.00
| Facility | | $500.00 | $1,754.00 | $3,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.32 / $277.32 / $414.51
| Professional | | $277.32 | $277.32 | $414.51 |