- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.00 / $816.00 / $1,368.90
| Professional | | $816.00 | $816.00 | $1,368.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.82 / $2,916.82 / $2,916.82
| Facility | | $2,916.82 | $2,916.82 | $2,916.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.00 / $816.00 / $816.00
| Professional | | $816.00 | $816.00 | $816.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.82 / $2,916.82 / $2,916.82
| Facility | | $2,916.82 | $2,916.82 | $2,916.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.00 / $816.00 / $816.00
| Professional | | $816.00 | $816.00 | $816.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.00 / $800.00 / $1,230.65
| Professional | | $760.00 | $800.00 | $1,230.65 |