- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $931.00 / $2,100.00
| Facility | | $318.75 | $931.00 | $2,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $318.75 / $342.08
| Professional | | $250.00 | $318.75 | $342.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.72 / $1,159.06 / $1,678.91
| Facility | | $854.72 | $1,159.06 | $1,678.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.42 / $366.42 / $366.42
| Facility | | $366.42 | $366.42 | $366.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.84 / $1,761.84 / $1,761.84
| Professional | | $1,761.84 | $1,761.84 | $1,761.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $430.31
| Facility | | $318.75 | $318.75 | $430.31 |