- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.00 / $1,816.00 / $2,235.00
| Facility | | $250.00 | $1,816.00 | $2,235.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $318.75 / $475.00
| Professional | | $250.00 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.01 / $630.00 / $1,236.33
| Facility | | $190.01 | $630.00 | $1,236.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.84 / $1,761.84 / $1,761.84
| Professional | | $1,761.84 | $1,761.84 | $1,761.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.01 / $40.01 / $40.01
| Professional | | $40.01 | $40.01 | $40.01 |