- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.21 / $81.48 / $88.45
| Professional | | $47.21 | $81.48 | $88.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.01 / $98.32 / $139.77
| Professional | | $64.01 | $98.32 | $139.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Facility | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.66 / $107.01 / $152.87
| Professional | | $77.66 | $107.01 | $152.87 |