- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,201.00 / $1,201.00
| Professional | | $1,201.00 | $1,201.00 | $1,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.47 / $362.47 / $423.88
| Professional | | $362.47 | $362.47 | $423.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $55.00 / $70.00
| Professional | | $50.00 | $55.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,587.34 / $1,587.34 / $1,587.34
| Facility | | $1,587.34 | $1,587.34 | $1,587.34 |