- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.00 / $1,675.00 / $2,345.00
| Facility | | $1,675.00 | $1,675.00 | $2,345.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.00 / $1,675.00 / $1,675.00
| Professional | | $1,675.00 | $1,675.00 | $1,675.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.10 / $1,380.10 / $1,380.10
| Facility | | $1,380.10 | $1,380.10 | $1,380.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.10 / $1,380.10 / $1,380.10
| Professional | | $1,380.10 | $1,380.10 | $1,380.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.00 / $1,675.00 / $2,093.75
| Professional | | $1,675.00 | $1,675.00 | $2,093.75 |