- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.48 / $404.13 / $404.13
| Professional | | $234.48 | $404.13 | $404.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.50 / $350.00 / $471.52
| Professional | | $297.50 | $350.00 | $471.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121,498.80 / $121,498.80 / $157,498.40
| Facility | | $121,498.80 | $121,498.80 | $157,498.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94,499.06 / $121,498.79 / $182,248.18
| Professional | | $94,499.06 | $121,498.79 | $182,248.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.51 / $104.51 / $462.00
| Professional | | $104.51 | $104.51 | $462.00 |