- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.67 / $642.35 / $1,036.08
| Facility | | $549.67 | $642.35 | $1,036.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.48 / $439.12 / $16,501.40
| Professional | | $280.48 | $439.12 | $16,501.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.00 / $3,329.10 / $3,329.10
| Professional | | $620.00 | $3,329.10 | $3,329.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- 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
- $1,140.69 / $3,329.10 / $3,329.10
| Professional | | $1,140.69 | $3,329.10 | $3,329.10 |