- 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 / $425.63
| Professional | | $250.00 | $318.75 | $425.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.63 / $3,246.55 / $5,186.10
| Facility | | $2,068.63 | $3,246.55 | $5,186.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.42 / $366.42 / $366.42
| Facility | | $366.42 | $366.42 | $366.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $430.31
| Facility | | $318.75 | $318.75 | $430.31 |