- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.46 / $1,027.46 / $1,027.46
| Facility | | $1,027.46 | $1,027.46 | $1,027.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.00 / $702.00 / $702.00
| Professional | | $702.00 | $702.00 | $702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $65.00 / $85.00
| Professional | | $50.00 | $65.00 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.00 / $702.00 / $702.00
| Professional | | $702.00 | $702.00 | $702.00 |