- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.00 / $240.00 / $240.00
| Facility | | $240.00 | $240.00 | $240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $240.00 / $240.00
| Professional | | $240.00 | $240.00 | $240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $45.00
| Professional | | $45.00 | $45.00 | $45.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.00 / $2,446.00 / $13,847.00
| Facility | | $2,312.00 | $2,446.00 | $13,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.62 / $253.40 / $505.54
| Professional | | $203.62 | $253.40 | $505.54 |