- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,653.57 / $4,911.29 / $6,345.25
| Facility | | $2,653.57 | $4,911.29 | $6,345.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $345.40
| Professional | | $100.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $2,500.00 / $2,500.00
| Professional | | $1,500.00 | $2,500.00 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.96 / $172.95 / $335.37
| Professional | | $112.96 | $172.95 | $335.37 |