- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.83 / $820.83 / $820.83
| Professional | | $820.83 | $820.83 | $820.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.00 / $3,854.00 / $4,625.00
| Professional | | $2,384.00 | $3,854.00 | $4,625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.65 / $1,044.43 / $1,508.62
| Professional | | $773.65 | $1,044.43 | $1,508.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.65 / $1,546.99 / $2,531.11
| Professional | | $780.65 | $1,546.99 | $2,531.11 |