- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.16 / $1,000.00 / $1,600.00
| Professional | | $199.16 | $1,000.00 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.92 / $2,509.05 / $2,599.12
| Professional | | $2,114.92 | $2,509.05 | $2,599.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.63 / $1,099.51 / $1,360.78
| Professional | | $1,088.63 | $1,099.51 | $1,360.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.16 / $1,000.00 / $2,197.00
| Facility | | $199.16 | $1,000.00 | $2,197.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,908.04 / $5,908.04 / $5,908.04
| Professional | | $5,908.04 | $5,908.04 | $5,908.04 |