- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.19 / $130.19 / $130.19
| Facility | | $130.19 | $130.19 | $130.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.24 / $391.24 / $391.24
| Facility | | $391.24 | $391.24 | $391.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $345.40
| Professional | | $100.00 | $150.00 | $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
- $32.34 / $2,500.00 / $2,500.00
| Professional | | $32.34 | $2,500.00 | $2,500.00 |