- 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
- $42.28 / $42.28 / $45.87
| Professional | | $42.28 | $42.28 | $45.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.23 / $60.18 / $70.59
| Professional | | $44.23 | $60.18 | $70.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,113.20 / $5,113.20 / $5,113.20
| Facility | | $5,113.20 | $5,113.20 | $5,113.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.57 / $56.39 / $107.61
| Professional | | $43.57 | $56.39 | $107.61 |