- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.10 / $343.10 / $2,356.00
| Facility | | $343.10 | $343.10 | $2,356.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.81 / $343.10 / $690.70
| Professional | | $325.81 | $343.10 | $690.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.00 / $1,603.10 / $2,531.50
| Professional | | $1,347.00 | $1,603.10 | $2,531.50 |
- 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 |