- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.40 / $1,199.51 / $1,606.49
| Professional | | $933.40 | $1,199.51 | $1,606.49 |
- 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 / $1,390.50
| Professional | | $1,147.50 | $1,350.00 | $1,390.50 |
- 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
- $1,350.00 / $1,350.00 / $1,390.50
| Professional | | $1,350.00 | $1,350.00 | $1,390.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.04 / $1,857.84 / $2,272.50
| Professional | | $889.04 | $1,857.84 | $2,272.50 |