- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $1,040.00 / $2,000.00
| Facility | | $500.00 | $1,040.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.00 / $393.00 / $393.00
| Professional | | $393.00 | $393.00 | $393.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,308.00
| Facility | | $1,000.00 | $1,000.00 | $1,308.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.00 / $397.00 / $397.00
| Professional | | $397.00 | $397.00 | $397.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $25.00
| Professional | | $17.00 | $20.00 | $25.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $610.00 / $1,305.00 / $3,046.00
| Facility | | $610.00 | $1,305.00 | $3,046.00 |