- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.39 / $990.39 / $990.39
| Professional | | $990.39 | $990.39 | $990.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,877.00 / $4,652.00 / $5,582.00
| Professional | | $2,877.00 | $4,652.00 | $5,582.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.17 / $1,277.32 / $1,845.02
| Professional | | $946.17 | $1,277.32 | $1,845.02 |
- 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
- $945.98 / $1,674.62 / $3,012.11
| Professional | | $945.98 | $1,674.62 | $3,012.11 |