- 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
- $1,390.25 / $1,423.75 / $1,822.40
| Professional | | $1,390.25 | $1,423.75 | $1,822.40 |
- 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
- $1,649.45 / $2,089.98 / $3,394.63
| Professional | | $1,649.45 | $2,089.98 | $3,394.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.00 / $1,675.00 / $2,008.96
| Professional | | $1,675.00 | $1,675.00 | $2,008.96 |