- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.50 / $1,092.50 / $1,092.50
| Facility | | $1,092.50 | $1,092.50 | $1,092.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.50 / $788.50 / $788.50
| Professional | | $750.50 | $788.50 | $788.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.50 / $617.50 / $617.50
| Facility | | $617.50 | $617.50 | $617.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.56 / $1,091.56 / $1,364.45
| Professional | | $1,091.56 | $1,091.56 | $1,364.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.50 / $456.00 / $950.00
| Professional | | $332.50 | $456.00 | $950.00 |