- 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
- $94.91 / $151.08 / $297.98
| Professional | | $94.91 | $151.08 | $297.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.34 / $151.90 / $215.93
| Professional | | $103.34 | $151.90 | $215.93 |
- 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
- $126.57 / $179.59 / $256.55
| Professional | | $126.57 | $179.59 | $256.55 |