- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.29 / $2,700.00 / $2,700.00
| Professional | | $664.29 | $2,700.00 | $2,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.00 / $2,628.00 / $3,564.00
| Professional | | $1,626.00 | $2,628.00 | $3,564.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.73 / $987.80 / $1,443.71
| Professional | | $737.73 | $987.80 | $1,443.71 |
- 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
- $798.66 / $1,487.78 / $2,424.50
| Professional | | $798.66 | $1,487.78 | $2,424.50 |