- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,423.75 / $1,423.75 / $1,708.50
| Facility | | $1,423.75 | $1,423.75 | $1,708.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.75 / $1,423.75 / $1,668.30
| Professional | | $1,423.75 | $1,423.75 | $1,668.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.25 / $268.25 / $268.25
| Professional | | $268.25 | $268.25 | $268.25 |
- 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 / $1,675.00
| Professional | | $1,675.00 | $1,675.00 | $1,675.00 |