- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.86 / $2,052.11 / $2,748.37
| Professional | | $1,596.86 | $2,052.11 | $2,748.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,244.00
| Facility | | $2,200.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.00 / $2,200.00 / $2,266.00
| Professional | | $1,870.00 | $2,200.00 | $2,266.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,244.00
| Facility | | $2,200.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,266.00
| Professional | | $2,200.00 | $2,200.00 | $2,266.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.92 / $3,163.28 / $4,255.87
| Professional | | $1,508.92 | $3,163.28 | $4,255.87 |