- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $7,838.38 / $7,838.38
| Facility | | $1,000.00 | $7,838.38 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.00 / $410.00 / $410.00
| Professional | | $410.00 | $410.00 | $410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $70.00 / $1,500.00
| Professional | | $45.00 | $70.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.00 / $410.00 / $410.00
| Professional | | $410.00 | $410.00 | $410.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.00 / $1,158.00 / $1,401.00
| Facility | | $230.00 | $1,158.00 | $1,401.00 |