- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $450.00
| Professional | | $450.00 | $450.00 | $450.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.98 / $2,090.69 / $3,665.86
| Facility | | $1,377.98 | $2,090.69 | $3,665.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.32 / $1,835.32 / $4,088.54
| Professional | | $1,835.32 | $1,835.32 | $4,088.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,224.00 / $3,101.76 / $5,920.00
| Facility | | $1,224.00 | $3,101.76 | $5,920.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.80 / $1,141.80 / $1,804.94
| Professional | | $1,141.80 | $1,141.80 | $1,804.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,224.00 / $3,500.00 / $6,361.00
| Facility | | $1,224.00 | $3,500.00 | $6,361.00 |