- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.00 / $1,100.00 / $2,250.00
| Facility | | $575.00 | $1,100.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,057.17 / $8,057.17 / $8,057.17
| Professional | | $8,057.17 | $8,057.17 | $8,057.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.48 / $1,545.43 / $2,079.10
| Facility | | $1,273.48 | $1,545.43 | $2,079.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.70 / $662.70 / $662.70
| Professional | | $662.70 | $662.70 | $662.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.00 / $2,739.00 / $4,402.00
| Facility | | $750.00 | $2,739.00 | $4,402.00 |