- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.00 / $1,500.00 / $5,803.20
| Facility | | $781.00 | $1,500.00 | $5,803.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,559.86 / $3,106.51 / $4,179.26
| Facility | | $2,559.86 | $3,106.51 | $4,179.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,400.00 / $1,400.00
| Professional | | $1,400.00 | $1,400.00 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.00 / $750.00 / $1,326.00
| Facility | | $250.00 | $750.00 | $1,326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.97 / $31.97 / $47.79
| Professional | | $31.97 | $31.97 | $47.79 |