- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.62 / $151.62 / $389.00
| Facility | | $151.62 | $151.62 | $389.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.30 / $151.62 / $151.62
| Professional | | $112.30 | $151.62 | $151.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.00 / $180.55 / $289.52
| Professional | | $157.00 | $180.55 | $289.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,970.10 / $12,970.10 / $16,024.22
| Facility | | $12,970.10 | $12,970.10 | $16,024.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $60.00
| Professional | | $50.00 | $60.00 | $60.00 |