- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.76 / $983.76 / $983.76
| Professional | | $983.76 | $983.76 | $983.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,865.00 / $4,632.00 / $5,558.00
| Professional | | $2,865.00 | $4,632.00 | $5,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.44 / $1,316.85 / $1,902.11
| Professional | | $975.44 | $1,316.85 | $1,902.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.43 / $1,916.86 / $3,030.31
| Professional | | $936.43 | $1,916.86 | $3,030.31 |