- 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 / $1,300.00
| Professional | | $1,000.00 | $1,000.00 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.63 / $1,088.63 / $1,360.78
| Professional | | $1,088.63 | $1,088.63 | $1,360.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,430.00 / $2,197.00 / $3,562.00
| Facility | | $1,430.00 | $2,197.00 | $3,562.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.14 / $325.14 / $379.33
| Facility | | $325.14 | $325.14 | $379.33 |