- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.23 / $261.23 / $1,362.00
| Facility | | $261.23 | $261.23 | $1,362.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.54 / $261.23 / $293.23
| Professional | | $247.54 | $261.23 | $293.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.00 / $772.80 / $1,239.23
| Professional | | $672.00 | $772.80 | $1,239.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,362.61 / $13,362.61 / $16,297.02
| Facility | | $13,362.61 | $13,362.61 | $16,297.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |