- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $5,000.00 / $8,500.00
| Facility | | $5,000.00 | $5,000.00 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.59 / $3,210.20 / $4,208.64
| Professional | | $2,154.59 | $3,210.20 | $4,208.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,790.00 / $3,315.00 / $11,319.46
| Facility | | $2,790.00 | $3,315.00 | $11,319.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.65 / $1,525.65 / $1,525.65
| Professional | | $1,525.65 | $1,525.65 | $1,525.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,790.00 / $2,790.00 / $2,790.00
| Facility | | $2,790.00 | $2,790.00 | $2,790.00 |