- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.00 / $915.84 / $1,080.00
| Professional | | $864.00 | $915.84 | $1,080.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $2,400.00 / $2,400.00
| Facility | | $960.00 | $2,400.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.80 / $3,160.00 / $3,160.00
| Professional | | $1,144.80 | $3,160.00 | $3,160.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,144.80 / $1,144.80 / $2,170.88
| Facility | | $1,144.80 | $1,144.80 | $2,170.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.80 / $1,144.80 / $1,144.80
| Professional | | $1,144.80 | $1,144.80 | $1,144.80 |