- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.22 / $1,106.19 / $1,350.00
| Facility | | $331.22 | $1,106.19 | $1,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.22 / $1,172.56 / $1,172.56
| Professional | | $331.22 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.22 / $1,106.19 / $1,350.00
| Facility | | $331.22 | $1,106.19 | $1,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.22 / $1,172.56 / $1,216.81
| Professional | | $331.22 | $1,172.56 | $1,216.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $3,517.68
| Professional | | $1,172.56 | $1,172.56 | $3,517.68 |