- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.28 / $544.28 / $544.28
| Professional | | $544.28 | $544.28 | $544.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $4,797.00
| Professional | | $286.94 | $2,446.40 | $4,797.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.55 / $349.59 / $5,788.32
| Facility | | $272.55 | $349.59 | $5,788.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $4,797.00
| Professional | | $286.94 | $2,446.40 | $4,797.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.76 / $1,435.76 / $2,392.92
| Professional | | $1,435.76 | $1,435.76 | $2,392.92 |