- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.06 / $702.06 / $702.06
| Professional | | $702.06 | $702.06 | $702.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $2,187.00
| Facility | | $2,187.00 | $2,187.00 | $2,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.04 / $2,187.00 / $5,811.24
| Professional | | $418.04 | $2,187.00 | $5,811.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.30 / $520.32 / $7,012.16
| Facility | | $329.30 | $520.32 | $7,012.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.04 / $2,187.00 / $5,811.24
| Professional | | $418.04 | $2,187.00 | $5,811.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.88 / $1,866.88 / $3,111.47
| Professional | | $1,866.88 | $1,866.88 | $3,111.47 |