- 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
- $1,300.00 / $1,741.78 / $1,900.00
| Professional | | $1,300.00 | $1,741.78 | $1,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,794.56 / $4,914.87 / $6,209.53
| Facility | | $3,794.56 | $4,914.87 | $6,209.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.34 / $2,420.48 / $2,420.48
| Professional | | $1,694.34 | $2,420.48 | $2,420.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.51 / $1,306.51 / $1,306.51
| Facility | | $1,306.51 | $1,306.51 | $1,306.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.31 / $1,418.39 / $1,468.74
| Professional | | $850.31 | $1,418.39 | $1,468.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.11 / $2,851.08 / $4,310.96
| Professional | | $2,092.11 | $2,851.08 | $4,310.96 |