- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $1,125.00 / $6,262.40
| Facility | | $318.75 | $1,125.00 | $6,262.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $450.00
| Professional | | $318.75 | $318.75 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.13 / $385.88 / $481.00
| Professional | | $357.13 | $385.88 | $481.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.26 / $943.90 / $1,286.71
| Facility | | $620.26 | $943.90 | $1,286.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.00 / $575.00 / $575.00
| Professional | | $575.00 | $575.00 | $575.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.38 / $1,328.38 / $1,328.38
| Professional | | $1,328.38 | $1,328.38 | $1,328.38 |