- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.00 / $1,275.00 / $1,275.00
| Professional | | $1,200.00 | $1,275.00 | $1,275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $1,275.00
| Facility | | $1,275.00 | $1,275.00 | $1,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $1,275.00
| Professional | | $1,275.00 | $1,275.00 | $1,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.14 / $1,718.94 / $2,070.19
| Professional | | $1,380.14 | $1,718.94 | $2,070.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.00 / $1,250.00 / $1,312.50
| Professional | | $1,250.00 | $1,250.00 | $1,312.50 |