- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.69 / $875.69 / $875.69
| Professional | | $875.69 | $875.69 | $875.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.00 / $4,151.00 / $4,981.00
| Professional | | $2,568.00 | $4,151.00 | $4,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.03 / $1,197.48 / $1,729.70
| Professional | | $887.03 | $1,197.48 | $1,729.70 |
- 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
- $877.76 / $1,728.78 / $2,739.09
| Professional | | $877.76 | $1,728.78 | $2,739.09 |