- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.02 / $132.02 / $400.00
| Facility | | $132.02 | $132.02 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.96 / $132.02 / $212.99
| Professional | | $124.96 | $132.02 | $212.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.00 / $193.20 / $309.80
| Professional | | $168.00 | $193.20 | $309.80 |
- 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
- $209.86 / $209.86 / $209.86
| Professional | | $209.86 | $209.86 | $209.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |