- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $850.00 / $872.91
| Professional | | $850.00 | $850.00 | $872.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.53 / $1,696.53 / $1,696.53
| Professional | | $1,696.53 | $1,696.53 | $1,696.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,835.80 / $1,835.80 / $1,835.80
| Facility | | $1,835.80 | $1,835.80 | $1,835.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.80 / $1,835.80 / $1,835.80
| Professional | | $1,835.80 | $1,835.80 | $1,835.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,835.80 / $1,835.80 / $1,835.80
| Facility | | $1,835.80 | $1,835.80 | $1,835.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.28 / $1,582.59 / $1,835.80
| Professional | | $1,519.28 | $1,582.59 | $1,835.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $531.75 / $1,266.07
| Professional | | $531.75 | $531.75 | $1,266.07 |