- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,854.00 / $3,854.00 / $3,854.00
| Facility | | $3,854.00 | $3,854.00 | $3,854.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.03 / $57.50 / $102.00
| Professional | | $56.03 | $57.50 | $102.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.80 / $62.40 / $78.00
| Professional | | $46.80 | $62.40 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.03 / $63.68 / $121.33
| Facility | | $56.03 | $63.68 | $121.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.94 / $402.94 / $402.94
| Professional | | $402.94 | $402.94 | $402.94 |