- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.00 / $764.00 / $764.00
| Professional | | $764.00 | $764.00 | $764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.00 / $3,656.00 / $4,387.00
| Professional | | $2,261.00 | $3,656.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.69 / $1,008.03 / $1,456.04
| Professional | | $746.69 | $1,008.03 | $1,456.04 |
- 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
- $701.75 / $1,507.14 / $2,377.71
| Professional | | $701.75 | $1,507.14 | $2,377.71 |