- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.88 / $1,181.88 / $2,069.79
| Professional | | $1,181.88 | $1,181.88 | $2,069.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,308.36 / $2,308.36 / $2,308.36
| Facility | | $2,308.36 | $2,308.36 | $2,308.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,308.36 / $2,308.36 / $2,308.36
| Professional | | $2,308.36 | $2,308.36 | $2,308.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,620.00 / $2,600.30
| Facility | | $1,620.00 | $1,620.00 | $2,600.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.59 / $1,182.59 / $1,620.00
| Professional | | $1,182.59 | $1,182.59 | $1,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.31 / $1,041.48 / $1,604.89
| Professional | | $941.31 | $1,041.48 | $1,604.89 |