- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,344.60 / $1,344.60 / $1,344.60
| Facility | | $1,344.60 | $1,344.60 | $1,344.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.20 / $1,344.60 / $1,393.20
| Professional | | $1,312.20 | $1,344.60 | $1,393.20 |
- 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
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.80 / $1,263.19 / $1,454.63
| Professional | | $1,112.80 | $1,263.19 | $1,454.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,350.00
| Professional | | $1,350.00 | $1,350.00 | $1,350.00 |