- 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
- $268.68 / $320.54 / $413.54
| Facility | | $268.68 | $320.54 | $413.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.85 / $688.92 / $1,869.10
| Facility | | $322.85 | $688.92 | $1,869.10 |
- 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 |