- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.00 / $1,232.55 / $3,534.30
| Facility | | $1,188.00 | $1,232.55 | $3,534.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.00 / $1,232.55 / $1,262.25
| Professional | | $1,188.00 | $1,232.55 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $1,262.25
| Facility | | $500.00 | $500.00 | $1,262.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,670.63
| Professional | | $1,262.25 | $1,262.25 | $1,670.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.50 / $1,237.50 / $1,237.50
| Professional | | $1,237.50 | $1,237.50 | $1,237.50 |