- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $1,140.00 / $8,187.72
| Facility | | $500.00 | $1,140.00 | $8,187.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.95 / $1,942.95 / $1,942.95
| Professional | | $1,942.95 | $1,942.95 | $1,942.95 |
- 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
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.00 / $513.00 / $1,739.00
| Facility | | $225.00 | $513.00 | $1,739.00 |