- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.58 / $320.58 / $20,035.90
| Professional | | $320.58 | $320.58 | $20,035.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,215.41 / $5,215.41 / $5,215.41
| Facility | | $5,215.41 | $5,215.41 | $5,215.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,001.07 / $7,001.07 / $7,001.07
| Professional | | $7,001.07 | $7,001.07 | $7,001.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,215.41 / $5,215.41 / $5,215.41
| Facility | | $5,215.41 | $5,215.41 | $5,215.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.00 / $1,170.00 / $7,001.07
| Professional | | $1,170.00 | $1,170.00 | $7,001.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.07 / $3,125.73 / $7,199.21
| Professional | | $1,361.07 | $3,125.73 | $7,199.21 |