- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $1,514.00 / $2,100.00
| Facility | | $318.75 | $1,514.00 | $2,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $318.75
| Professional | | $318.75 | $318.75 | $318.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $565.19 / $631.00 / $817.72
| Facility | | $565.19 | $631.00 | $817.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.40 / $960.68 / $1,722.45
| Facility | | $435.40 | $960.68 | $1,722.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $400.51 / $600.00
| Facility | | $318.75 | $400.51 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.34 / $1,450.34 / $1,450.34
| Professional | | $1,450.34 | $1,450.34 | $1,450.34 |