- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.20 / $2,045.40 / $2,093.64
| Professional | | $1,593.20 | $2,045.40 | $2,093.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.83 / $2,100.40 / $2,100.40
| Professional | | $1,656.83 | $2,100.40 | $2,100.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,377.00
| Facility | | $1,350.00 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.50 / $1,350.00 / $1,377.00
| Professional | | $1,147.50 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.36 / $1,895.36 / $1,895.36
| Professional | | $1,895.36 | $1,895.36 | $1,895.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.26 / $1,378.98 / $2,052.14
| Professional | | $1,057.26 | $1,378.98 | $2,052.14 |