- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.25 / $1,272.25 / $2,228.05
| Professional | | $1,272.25 | $1,272.25 | $2,228.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,484.86 / $2,484.86 / $2,484.86
| Facility | | $2,484.86 | $2,484.86 | $2,484.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,484.86 / $2,484.86 / $2,484.86
| Professional | | $2,484.86 | $2,484.86 | $2,484.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $2,513.71
| Facility | | $1,800.00 | $1,800.00 | $2,513.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,314.00 / $1,800.00
| Professional | | $1,314.00 | $1,314.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.40 / $1,520.07 / $1,756.79
| Professional | | $1,030.40 | $1,520.07 | $1,756.79 |