- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.56 / $114.56 / $375.00
| Facility | | $114.56 | $114.56 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.62 / $114.56 / $182.36
| Professional | | $107.62 | $114.56 | $182.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.00 / $163.30 / $261.86
| Professional | | $142.00 | $163.30 | $261.86 |
- 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
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |