- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,048.00 / $5,000.00 / $5,000.00
| Facility | | $2,048.00 | $5,000.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.65 / $1,027.21 / $1,685.87
| Facility | | $743.65 | $1,027.21 | $1,685.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.94 / $1,808.58 / $3,155.56
| Professional | | $1,476.94 | $1,808.58 | $3,155.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.28 / $709.16 / $960.24
| Professional | | $349.28 | $709.16 | $960.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.60 / $2,018.50 / $3,787.18
| Professional | | $1,744.60 | $2,018.50 | $3,787.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,980.00 / $5,000.00 / $5,000.00
| Facility | | $1,980.00 | $5,000.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $5,000.00
| Professional | | $1,000.00 | $1,000.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.24 / $1,807.85 / $3,270.47
| Professional | | $1,178.24 | $1,807.85 | $3,270.47 |