- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.70 / $164.70 / $179.84
| Professional | | $164.70 | $164.70 | $179.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.38 / $270.27 / $358.07
| Facility | | $199.38 | $270.27 | $358.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $509.30
| Professional | | $3.00 | $3.00 | $509.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.00 / $2,000.00 / $12,000.00
| Facility | | $414.00 | $2,000.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.94 / $1,314.24 / $1,314.24
| Professional | | $1,184.94 | $1,314.24 | $1,314.24 |