- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.55 / $3,600.00 / $3,600.00
| Professional | | $2,181.55 | $3,600.00 | $3,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,750.65 / $2,750.65 / $2,750.65
| Facility | | $2,750.65 | $2,750.65 | $2,750.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,750.65 / $2,750.65 / $2,750.65
| Professional | | $2,750.65 | $2,750.65 | $2,750.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,750.65 / $2,750.65 / $2,750.65
| Facility | | $2,750.65 | $2,750.65 | $2,750.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.30 / $1,707.30 / $2,750.65
| Professional | | $1,707.30 | $1,707.30 | $2,750.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $796.74 / $1,897.00
| Professional | | $796.74 | $796.74 | $1,897.00 |