- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.00 / $911.00 / $911.00
| Professional | | $911.00 | $911.00 | $911.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.65 / $1,148.65 / $1,148.65
| Facility | | $1,148.65 | $1,148.65 | $1,148.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.25 / $1,137.82 / $1,148.65
| Professional | | $910.25 | $1,137.82 | $1,148.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.65 / $1,148.65 / $1,148.65
| Facility | | $1,148.65 | $1,148.65 | $1,148.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.17 / $950.60 / $1,148.65
| Professional | | $792.17 | $950.60 | $1,148.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.71 / $332.71 / $1,356.31
| Professional | | $332.71 | $332.71 | $1,356.31 |