- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,250.00 / $3,833.00 / $6,917.00
| Facility | | $1,250.00 | $3,833.00 | $6,917.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.00 / $1,250.00 / $1,250.00
| Professional | | $1,250.00 | $1,250.00 | $1,250.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.78 / $256.47 / $1,665.85
| Facility | | $166.78 | $256.47 | $1,665.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.27 / $1,530.86 / $1,578.97
| Professional | | $1,345.27 | $1,530.86 | $1,578.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.37 / $126.37 / $126.37
| Professional | | $126.37 | $126.37 | $126.37 |