- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,215.40 / $3,215.40 / $3,215.40
| Facility | | $3,215.40 | $3,215.40 | $3,215.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $3.00
| Professional | | $3.00 | $3.00 | $3.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $200.00 / $345.40
| Professional | | $120.00 | $200.00 | $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
- $1,500.00 / $2,500.00 / $2,500.00
| Professional | | $1,500.00 | $2,500.00 | $2,500.00 |