- 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
- $41.27 / $44.51 / $78.16
| Professional | | $41.27 | $44.51 | $78.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.50 / $71.54 / $112.94
| Professional | | $41.50 | $71.54 | $112.94 |
- 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
- $70.00 / $94.26 / $160.16
| Professional | | $70.00 | $94.26 | $160.16 |