- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,485.00 / $1,485.00
| Facility | | $1,485.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.07 / $1,485.00 / $1,485.00
| Professional | | $1,218.07 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.12 / $1,250.36 / $1,459.17
| Facility | | $1,007.12 | $1,250.36 | $1,459.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.36 / $1,250.36 / $1,250.36
| Professional | | $1,250.36 | $1,250.36 | $1,250.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,670.63
| Professional | | $1,262.25 | $1,262.25 | $1,670.63 |