- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.00 / $306.00 / $7,458.80
| Professional | | $306.00 | $306.00 | $7,458.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.38 / $1,698.38 / $1,698.38
| Facility | | $1,698.38 | $1,698.38 | $1,698.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.50 / $1,788.50 / $1,941.55
| Facility | | $1,788.50 | $1,788.50 | $1,941.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.14 / $2,606.14 / $2,606.14
| Professional | | $2,606.14 | $2,606.14 | $2,606.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.50 / $1,788.50 / $1,941.55
| Facility | | $1,788.50 | $1,788.50 | $1,941.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $2,606.14
| Professional | | $50.00 | $50.00 | $2,606.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.69 / $1,160.00 / $5,220.00
| Professional | | $506.69 | $1,160.00 | $5,220.00 |