- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.16 / $984.16 / $984.16
| Professional | | $984.16 | $984.16 | $984.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,882.00 / $4,659.00 / $5,591.00
| Professional | | $2,882.00 | $4,659.00 | $5,591.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.24 / $1,357.07 / $1,960.22
| Professional | | $1,005.24 | $1,357.07 | $1,960.22 |
- 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
- $991.45 / $1,945.40 / $3,104.38
| Professional | | $991.45 | $1,945.40 | $3,104.38 |