- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $557.80 / $1,667.00
| Facility | | $318.75 | $557.80 | $1,667.00 |
- 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
- $230.56 / $241.72 / $481.00
| Professional | | $230.56 | $241.72 | $481.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.33 / $867.60 / $1,094.21
| Facility | | $511.33 | $867.60 | $1,094.21 |
- 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
- $1,621.70 / $1,621.70 / $1,621.70
| Professional | | $1,621.70 | $1,621.70 | $1,621.70 |