- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.83 / $322.83 / $322.83
| Professional | | $322.83 | $322.83 | $322.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,440.00
| Facility | | $1,440.00 | $1,440.00 | $1,440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.64 / $1,440.00 / $2,484.39
| Professional | | $233.64 | $1,440.00 | $2,484.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.58 / $1,608.94 / $3,975.02
| Facility | | $330.58 | $1,608.94 | $3,975.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.64 / $1,440.00 / $2,484.39
| Professional | | $233.64 | $1,440.00 | $2,484.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.04 / $1,391.26 / $2,318.76
| Professional | | $1,267.04 | $1,391.26 | $2,318.76 |