- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.00 / $5,000.00 / $9,596.00
| Facility | | $1,300.00 | $5,000.00 | $9,596.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.00 / $1,300.00 / $1,300.00
| Professional | | $1,300.00 | $1,300.00 | $1,300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $938.20 / $2,809.00 / $4,185.00
| Facility | | $938.20 | $2,809.00 | $4,185.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.31 / $938.20 / $1,294.71
| Professional | | $823.31 | $938.20 | $1,294.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.42 / $1,238.42 / $2,514.67
| Professional | | $1,238.42 | $1,238.42 | $2,514.67 |