- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.05 / $1,199.05 / $1,199.05
| Professional | | $1,167.05 | $1,199.05 | $1,199.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.33 / $1,344.71 / $2,076.75
| Professional | | $1,027.33 | $1,344.71 | $2,076.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $5,000.00 / $5,000.00
| Facility | | $5,000.00 | $5,000.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.97 / $1,196.65 / $2,668.51
| Professional | | $986.97 | $1,196.65 | $2,668.51 |