- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.06 / $677.06 / $677.06
| Professional | | $677.06 | $677.06 | $677.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.00 / $1,440.00 / $2,101.00
| Professional | | $1,200.00 | $1,440.00 | $2,101.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.80 / $1,118.07 / $1,392.28
| Professional | | $767.80 | $1,118.07 | $1,392.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.16 / $1,492.35 / $2,403.69
| Professional | | $876.16 | $1,492.35 | $2,403.69 |