- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.35 / $844.35 / $844.35
| Professional | | $844.35 | $844.35 | $844.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,438.00 / $3,942.00 / $4,730.00
| Professional | | $2,438.00 | $3,942.00 | $4,730.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.82 / $1,043.31 / $1,507.00
| Professional | | $772.82 | $1,043.31 | $1,507.00 |
- 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
- $785.86 / $1,566.50 / $2,444.00
| Professional | | $785.86 | $1,566.50 | $2,444.00 |