- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $6,907.00
| Facility | | $6,907.00 | $6,907.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.14 / $1,295.15 / $1,295.15
| Professional | | $1,268.14 | $1,295.15 | $1,295.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.64 / $1,584.49 / $2,243.19
| Professional | | $1,157.64 | $1,584.49 | $2,243.19 |
- 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
- $1,122.95 / $1,458.93 / $2,917.13
| Professional | | $1,122.95 | $1,458.93 | $2,917.13 |