- 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
- $983.94 / $1,194.06 / $1,606.40
| Facility | | $983.94 | $1,194.06 | $1,606.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $849.00
| Professional | | $25.00 | $25.00 | $849.00 |
- 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
- $197.38 / $197.38 / $295.02
| Professional | | $197.38 | $197.38 | $295.02 |