- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.27 / $265.27 / $1,100.00
| Facility | | $265.27 | $265.27 | $1,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.36 / $265.27 / $293.23
| Professional | | $251.36 | $265.27 | $293.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.00 / $470.96 / $748.70
| Professional | | $406.00 | $470.96 | $748.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,010.50 / $13,010.50 / $16,052.30
| Facility | | $13,010.50 | $13,010.50 | $16,052.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $60.00
| Professional | | $50.00 | $60.00 | $60.00 |