- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.56 / $457.38 / $4,905.00
| Professional | | $322.56 | $457.38 | $4,905.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.00 / $930.00 / $1,407.00
| Professional | | $623.00 | $930.00 | $1,407.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.39 / $701.22 / $1,374.68
| Professional | | $422.39 | $701.22 | $1,374.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.60 / $968.18 / $1,504.95
| Professional | | $501.60 | $968.18 | $1,504.95 |