- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.20 / $1,333.20 / $2,352.40
| Professional | | $1,333.20 | $1,333.20 | $2,352.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,588.80 / $2,588.80 / $2,588.80
| Professional | | $2,588.80 | $2,588.80 | $2,588.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $2,677.79
| Facility | | $1,350.00 | $1,350.00 | $2,677.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,350.00
| Professional | | $1,350.00 | $1,350.00 | $1,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.70 / $1,333.56 / $1,625.61
| Professional | | $1,189.70 | $1,333.56 | $1,625.61 |