- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.25 / $105.25 / $330.00
| Facility | | $105.25 | $105.25 | $330.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.53 / $105.25 / $109.32
| Professional | | $99.53 | $105.25 | $109.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.00 / $161.24 / $256.32
| Professional | | $139.00 | $161.24 | $256.32 |
- 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 |