- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.91 / $619.91 / $619.91
| Professional | | $619.91 | $619.91 | $619.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $5,182.32
| Professional | | $386.96 | $3,621.85 | $5,182.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,625.86 / $3,282.33 / $6,253.28
| Facility | | $2,625.86 | $3,282.33 | $6,253.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $5,182.32
| Professional | | $386.96 | $3,621.85 | $5,182.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.20 / $1,852.20 / $3,087.00
| Professional | | $1,852.20 | $1,852.20 | $3,087.00 |