- 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
- $80.06 / $80.06 / $88.44
| Professional | | $80.06 | $80.06 | $88.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.91 / $108.39 / $128.74
| Professional | | $74.91 | $108.39 | $128.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.93 / $97.83 / $204.63
| Professional | | $73.93 | $97.83 | $204.63 |