- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.25 / $1,199.25 / $1,383.75
| Professional | | $1,199.25 | $1,199.25 | $1,383.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,620.00 / $1,806.26
| Facility | | $1,620.00 | $1,620.00 | $1,806.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.59 / $1,620.00 / $1,668.60
| Professional | | $1,182.59 | $1,620.00 | $1,668.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,620.00 / $1,806.26
| Facility | | $1,620.00 | $1,620.00 | $1,806.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.59 / $1,620.00 / $1,668.60
| Professional | | $1,182.59 | $1,620.00 | $1,668.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.35 / $1,455.76 / $2,841.03
| Professional | | $817.35 | $1,455.76 | $2,841.03 |