- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $35,549.33 / $35,549.33
| Facility | | $4,500.00 | $35,549.33 | $35,549.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Professional | | $4,500.00 | $4,500.00 | $4,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $3,500.00 / $3,900.00
| Professional | | $30.00 | $3,500.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,132.46 / $1,579.31 / $2,488.17
| Facility | | $1,132.46 | $1,579.31 | $2,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,620.00 / $4,150.00 / $4,441.00
| Facility | | $2,620.00 | $4,150.00 | $4,441.00 |