- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.37 / $441.37 / $532.99
| Professional | | $441.37 | $441.37 | $532.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $543.75 / $715.35 / $1,058.69
| Facility | | $543.75 | $715.35 | $1,058.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $1,589.90
| Professional | | $3.00 | $3.00 | $1,589.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.34 / $1,098.05 / $16,394.00
| Facility | | $977.34 | $1,098.05 | $16,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,955.00 / $2,955.00 / $2,955.00
| Professional | | $2,955.00 | $2,955.00 | $2,955.00 |