- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.50 / $536.57 / $3,510.00
| Professional | | $362.50 | $536.57 | $3,510.00 |
- 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
- $701.00 / $1,015.00 / $1,535.00
| Professional | | $701.00 | $1,015.00 | $1,535.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.97 / $787.04 / $1,495.62
| Professional | | $486.97 | $787.04 | $1,495.62 |
- 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
- $580.64 / $1,053.85 / $1,691.31
| Professional | | $580.64 | $1,053.85 | $1,691.31 |