- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.87 / $723.59 / $3,988.02
| Professional | | $578.87 | $723.59 | $3,988.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $4,684.28
| Professional | | $150.00 | $150.00 | $4,684.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.22 / $2,386.08 / $3,727.13
| Facility | | $612.22 | $2,386.08 | $3,727.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.86 / $2,728.85 / $8,197.86
| Professional | | $589.86 | $2,728.85 | $8,197.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.00 / $3,275.00 / $3,275.00
| Facility | | $3,275.00 | $3,275.00 | $3,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.28 / $2,064.00 / $3,275.00
| Professional | | $492.28 | $2,064.00 | $3,275.00 |