- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.95 / $847.95 / $847.95
| Professional | | $847.95 | $847.95 | $847.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.00 / $1,877.00 / $2,815.00
| Professional | | $1,564.00 | $1,877.00 | $2,815.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.35 / $1,403.81 / $1,928.82
| Professional | | $1,095.35 | $1,403.81 | $1,928.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.40 / $2,450.80 / $3,239.27
| Professional | | $1,225.40 | $2,450.80 | $3,239.27 |