- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,390.25 / $1,390.25 / $1,390.25
| Facility | | $1,390.25 | $1,390.25 | $1,390.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.25 / $1,390.25 / $1,390.25
| Professional | | $1,390.25 | $1,390.25 | $1,390.25 |
- 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
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- 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 |