- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.00 / $1,178.00 / $1,178.00
| Professional | | $1,178.00 | $1,178.00 | $1,178.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.06 / $1,590.06 / $1,590.06
| Facility | | $1,590.06 | $1,590.06 | $1,590.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.56 / $1,091.56 / $1,364.45
| Professional | | $1,091.56 | $1,091.56 | $1,364.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.06 / $1,590.06 / $1,590.06
| Facility | | $1,590.06 | $1,590.06 | $1,590.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.50 / $1,091.56 / $1,364.45
| Professional | | $617.50 | $1,091.56 | $1,364.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.00 / $570.00 / $1,330.00
| Professional | | $570.00 | $570.00 | $1,330.00 |