- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.72 / $136.72 / $750.00
| Facility | | $136.72 | $136.72 | $750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.33 / $136.72 / $231.31
| Professional | | $129.33 | $136.72 | $231.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.00 / $440.45 / $706.29
| Professional | | $383.00 | $440.45 | $706.29 |
- 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
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |