- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.48 / $404.13 / $593.33
| Professional | | $234.48 | $404.13 | $593.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.50 / $350.00 / $621.14
| Professional | | $297.50 | $350.00 | $621.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121,498.80 / $121,498.80 / $121,498.80
| Facility | | $121,498.80 | $121,498.80 | $121,498.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.51 / $104.51 / $104.51
| Professional | | $104.51 | $104.51 | $104.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.51 / $104.51 / $104.51
| Professional | | $104.51 | $104.51 | $104.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |