- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.76 / $418.76 / $418.76
| Professional | | $418.76 | $418.76 | $418.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.24 / $299.52 / $2,440.86
| Professional | | $174.24 | $299.52 | $2,440.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.00 / $614.00 / $676.00
| Professional | | $614.00 | $614.00 | $676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.20 / $111.10 / $1,094.90
| Professional | | $105.20 | $111.10 | $1,094.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.05 / $210.14 / $12,000.00
| Facility | | $118.05 | $210.14 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.38 / $2,135.81 / $2,289.21
| Professional | | $525.38 | $2,135.81 | $2,289.21 |