- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $6,907.00
| Facility | | $6,907.00 | $6,907.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.97 / $113.62 / $136.12
| Professional | | $60.97 | $113.62 | $136.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.71 / $140.83 / $167.12
| Professional | | $62.71 | $140.83 | $167.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.18 / $150.18 / $150.18
| Professional | | $150.18 | $150.18 | $150.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.90 / $128.87 / $203.90
| Professional | | $110.90 | $128.87 | $203.90 |