- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.00 / $3,742.00 / $18,600.00
| Facility | | $1,300.00 | $3,742.00 | $18,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.92 / $1,570.92 / $6,245.00
| Professional | | $1,570.92 | $1,570.92 | $6,245.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,772.28 / $7,542.87 / $12,010.09
| Facility | | $4,772.28 | $7,542.87 | $12,010.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.00 / $1,723.87 / $6,272.82
| Facility | | $250.00 | $1,723.87 | $6,272.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.00 / $1,760.00 / $6,155.68
| Facility | | $350.00 | $1,760.00 | $6,155.68 |