- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.33 / $105.33 / $105.33
| Facility | | $105.33 | $105.33 | $105.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $114.30 / $140.44
| Professional | | $105.33 | $114.30 | $140.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $372.00 / $372.00 / $717.96
| Facility | | $372.00 | $372.00 | $717.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.00 / $372.00 / $528.24
| Professional | | $372.00 | $372.00 | $528.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,649.61 / $16,774.95 / $23,574.89
| Facility | | $15,649.61 | $16,774.95 | $23,574.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.57 / $230.57 / $230.57
| Professional | | $230.57 | $230.57 | $230.57 |