- 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
- $1,000.00 / $1,000.00 / $1,288.25
| Professional | | $1,000.00 | $1,000.00 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,466.84 / $8,709.64
| Facility | | $3,388.44 | $4,466.84 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,348.96
| Professional | | $1,096.48 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $676.08 / $1,905.46
| Facility | | $501.19 | $676.08 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $602.56 / $954.99
| Facility | | $380.19 | $602.56 | $954.99 |