- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $5,408.00 / $9,676.00
| Facility | | $1,440.00 | $5,408.00 | $9,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,200.00 / $1,950.00
| Professional | | $1,000.00 | $1,200.00 | $1,950.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.00 / $3,476.00 / $4,419.00
| Facility | | $101.00 | $3,476.00 | $4,419.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.06 / $228.06 / $228.06
| Facility | | $228.06 | $228.06 | $228.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $444.09 / $444.09 / $444.09
| Facility | | $444.09 | $444.09 | $444.09 |