- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.22 / $896.22 / $896.22
| Facility | | $896.22 | $896.22 | $896.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.43 / $896.22 / $896.22
| Professional | | $828.43 | $896.22 | $896.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Professional | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.14 / $517.14 / $1,323.27
| Professional | | $517.14 | $517.14 | $1,323.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.33 / $526.28 / $851.03
| Professional | | $358.33 | $526.28 | $851.03 |