- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $8,500.00
| Facility | | $2,000.00 | $2,000.00 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.30 / $449.10 / $1,246.50
| Professional | | $249.30 | $449.10 | $1,246.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.93 / $1,917.93 / $1,917.93
| Professional | | $1,917.93 | $1,917.93 | $1,917.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,268.56 / $5,268.56 / $5,268.56
| Facility | | $5,268.56 | $5,268.56 | $5,268.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.32 / $390.32 / $390.32
| Facility | | $390.32 | $390.32 | $390.32 |