- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.15 / $765.51 / $765.51
| Professional | | $750.15 | $765.51 | $765.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.00 / $4,688.00 / $5,626.00
| Professional | | $2,900.00 | $4,688.00 | $5,626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.09 / $1,169.22 / $1,688.87
| Professional | | $866.09 | $1,169.22 | $1,688.87 |
- 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
- $908.09 / $1,818.64 / $2,826.90
| Professional | | $908.09 | $1,818.64 | $2,826.90 |