- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.50 / $452.14 / $2,086.75
| Professional | | $282.50 | $452.14 | $2,086.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.00 / $1,250.00 / $1,935.00
| Professional | | $836.00 | $1,250.00 | $1,935.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.77 / $623.48 / $1,072.56
| Professional | | $347.77 | $623.48 | $1,072.56 |
- 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
- $479.67 / $858.06 / $1,756.92
| Professional | | $479.67 | $858.06 | $1,756.92 |