- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $616.60 / $776.25
| Professional | | $302.00 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $50,118.72 / $50,118.72
| Facility | | $7,762.47 | $50,118.72 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,862.09
| Professional | | $1,698.24 | $1,698.24 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $229.09 / $407.38
| Facility | | $177.83 | $229.09 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $309.03 / $354.81
| Professional | | $5.01 | $309.03 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $234.42 / $407.38
| Facility | | $177.83 | $234.42 | $407.38 |