- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.80 / $125.80 / $638.00
| Facility | | $125.80 | $125.80 | $638.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.34 / $125.80 / $187.41
| Professional | | $119.34 | $125.80 | $187.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $174.00 / $276.61
| Professional | | $150.00 | $174.00 | $276.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,796.87 / $12,796.87 / $15,903.78
| Facility | | $12,796.87 | $12,796.87 | $15,903.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |