- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $915.68
| Facility | | $500.00 | $500.00 | $915.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $915.68 / $915.68
| Professional | | $500.00 | $915.68 | $915.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.08 / $872.08 / $872.08
| Professional | | $872.08 | $872.08 | $872.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $872.08 / $872.08 / $872.08
| Facility | | $872.08 | $872.08 | $872.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.08 / $872.08 / $872.08
| Professional | | $872.08 | $872.08 | $872.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $493.00
| Professional | | $100.00 | $200.00 | $493.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.08 / $872.08 / $872.08
| Professional | | $872.08 | $872.08 | $872.08 |