- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,237.34
| Professional | | $1,448.30 | $1,448.30 | $2,237.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.00 / $350.00 / $483.00
| Professional | | $280.00 | $350.00 | $483.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,886.20 / $175,498.30 / $188,323.10
| Facility | | $3,886.20 | $175,498.30 | $188,323.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121,498.79 / $121,498.79 / $121,498.79
| Professional | | $121,498.79 | $121,498.79 | $121,498.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $462.00
| Professional | | $198.37 | $198.37 | $462.00 |