- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.57 / $1,060.57 / $1,060.57
| Facility | | $1,060.57 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.77 / $1,060.57 / $1,060.57
| Professional | | $433.77 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.00 / $541.00 / $541.00
| Facility | | $541.00 | $541.00 | $541.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $60.00 / $70.20
| Professional | | $45.00 | $60.00 | $70.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $300.00 / $300.00
| Facility | | $300.00 | $300.00 | $300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.00 / $446.00 / $446.00
| Facility | | $318.00 | $446.00 | $446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |