- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.12 / $308.12 / $308.12
| Professional | | $308.12 | $308.12 | $308.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $2,160.00
| Facility | | $2,160.00 | $2,160.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.39 / $2,160.00 / $2,845.32
| Professional | | $259.39 | $2,160.00 | $2,845.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.30 / $315.51 / $2,529.41
| Facility | | $189.30 | $315.51 | $2,529.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.39 / $2,160.00 / $2,845.32
| Professional | | $259.39 | $2,160.00 | $2,845.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.83 / $1,469.64 / $1,469.64
| Professional | | $1,233.83 | $1,469.64 | $1,469.64 |