- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.66 / $109.66 / $280.62
| Professional | | $109.66 | $109.66 | $280.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.41 / $300.77 / $421.38
| Facility | | $134.41 | $300.77 | $421.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.50 / $503.50 / $503.50
| Professional | | $503.50 | $503.50 | $503.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.05 / $268.35 / $12,000.00
| Facility | | $252.05 | $268.35 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.00 / $1,149.42 / $1,149.42
| Professional | | $1,021.00 | $1,149.42 | $1,149.42 |