- 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
- $64.80 / $114.87 / $144.02
| Professional | | $64.80 | $114.87 | $144.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.19 / $114.69 / $189.61
| Professional | | $60.19 | $114.69 | $189.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.20 / $58.20 / $107.68
| Professional | | $58.20 | $58.20 | $107.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.38 / $140.63 / $272.17
| Professional | | $100.38 | $140.63 | $272.17 |