- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $800.00 / $5,759.01
| Facility | | $318.75 | $800.00 | $5,759.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $318.75 / $425.00
| Professional | | $275.00 | $318.75 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.04 / $720.91 / $969.86
| Facility | | $594.04 | $720.91 | $969.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.00 / $758.63 / $3,138.00
| Facility | | $600.00 | $758.63 | $3,138.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.81 / $1,940.81 / $1,940.81
| Professional | | $1,940.81 | $1,940.81 | $1,940.81 |