- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.35 / $1,550.35 / $1,550.35
| Professional | | $1,550.35 | $1,550.35 | $1,550.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,244.00
| Facility | | $2,200.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.66 / $2,200.00 / $5,231.25
| Professional | | $354.66 | $2,200.00 | $5,231.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.85 / $2,470.73 / $4,273.28
| Professional | | $1,531.85 | $2,470.73 | $4,273.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.35 / $2,263.38 / $3,445.23
| Professional | | $1,550.35 | $2,263.38 | $3,445.23 |