- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,513.56
| Professional | | $562.34 | $562.34 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $91,201.08
| Facility | | $537.03 | $758.58 | $91,201.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $1,621.81
| Facility | | $616.60 | $616.60 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $616.60
| Professional | | $562.34 | $562.34 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $575.44 / $1,659.59
| Facility | | $537.03 | $575.44 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $575.44 / $1,659.59
| Professional | | $537.03 | $575.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $1,621.81
| Facility | | $616.60 | $616.60 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $562.34 / $794.33
| Professional | | $79.43 | $562.34 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |