- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.72 / $663.72 / $663.72
| Professional | | $663.72 | $663.72 | $663.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $2,900.00
| Facility | | $2,900.00 | $2,900.00 | $2,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $5,107.45
| Professional | | $480.34 | $2,900.00 | $5,107.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.65 / $3,307.68 / $8,171.92
| Facility | | $679.65 | $3,307.68 | $8,171.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $5,107.45
| Professional | | $480.34 | $2,900.00 | $5,107.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,604.80 / $2,860.46 / $4,767.43
| Professional | | $2,604.80 | $2,860.46 | $4,767.43 |