- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.86 / $184.86 / $386.00
| Facility | | $184.86 | $184.86 | $386.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.72 / $184.86 / $206.97
| Professional | | $128.72 | $184.86 | $206.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.00 / $98.40 / $167.16
| Professional | | $82.00 | $98.40 | $167.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,663.81 / $12,663.81 / $15,811.30
| Facility | | $12,663.81 | $12,663.81 | $15,811.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $60.00
| Professional | | $50.00 | $50.00 | $60.00 |