- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Facility | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.50 / $1,377.00 / $1,377.00
| Professional | | $1,300.50 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Facility | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Professional | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.50 / $1,350.00 / $1,350.00
| Professional | | $1,147.50 | $1,350.00 | $1,350.00 |