- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.25 / $475.25 / $594.05
| Professional | | $475.25 | $475.25 | $594.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36,414.80 / $36,414.80 / $36,414.80
| Facility | | $36,414.80 | $36,414.80 | $36,414.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.00 / $3,329.10 / $3,329.10
| Professional | | $584.00 | $3,329.10 | $3,329.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.66 / $260.66 / $584.00
| Facility | | $260.66 | $260.66 | $584.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.66 / $467.00 / $618.95
| Professional | | $260.66 | $467.00 | $618.95 |