- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,423.75 / $1,423.75 / $1,423.75
| Facility | | $1,423.75 | $1,423.75 | $1,423.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.50 / $1,423.75 / $1,423.75
| Professional | | $1,373.50 | $1,423.75 | $1,423.75 |
- 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 / $1,989.06
| Professional | | $1,675.00 | $1,675.00 | $1,989.06 |