- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,555.10 / $28,555.10 / $28,555.10
| Professional | | $28,555.10 | $28,555.10 | $28,555.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.76 / $64.16 / $116.00
| Facility | | $17.76 | $64.16 | $116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.40 / $59.20 / $80.66
| Professional | | $44.40 | $59.20 | $80.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,682.23 / $2,682.23 / $2,682.23
| Professional | | $2,682.23 | $2,682.23 | $2,682.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,703.06
| Facility | | $100.00 | $100.00 | $1,703.06 |