- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,034.00 / $5,650.00
| Facility | | $1,000.00 | $3,034.00 | $5,650.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $2,200.00
| Professional | | $1,000.00 | $1,000.00 | $2,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,250.38 / $2,250.38 / $4,034.43
| Facility | | $2,250.38 | $2,250.38 | $4,034.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.80 / $1,613.27 / $1,897.97
| Professional | | $1,543.80 | $1,613.27 | $1,897.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.71 / $95.71 / $95.71
| Professional | | $95.71 | $95.71 | $95.71 |