- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.50 / $1,557.50 / $2,766.80
| Professional | | $1,557.50 | $1,557.50 | $2,766.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,024.30 / $3,024.30 / $3,024.30
| Professional | | $3,024.30 | $3,024.30 | $3,024.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $3,128.37
| Facility | | $1,950.00 | $1,950.00 | $3,128.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Professional | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.57 / $1,310.17 / $1,451.95
| Professional | | $1,228.57 | $1,310.17 | $1,451.95 |