- 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
- $75.48 / $99.38 / $120.35
| Professional | | $75.48 | $99.38 | $120.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.95 / $118.48 / $169.48
| Professional | | $80.95 | $118.48 | $169.48 |
- 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
- $108.76 / $137.54 / $271.64
| Professional | | $108.76 | $137.54 | $271.64 |