- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.05 / $1,489.86 / $1,635.00
| Professional | | $1,423.05 | $1,489.86 | $1,635.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,400.00 / $2,400.00
| Facility | | $2,400.00 | $2,400.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.00 / $1,752.00 / $2,400.00
| Professional | | $1,752.00 | $1,752.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,376.76 / $3,376.76 / $3,376.76
| Professional | | $3,376.76 | $3,376.76 | $3,376.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.58 / $1,848.33 / $2,598.56
| Professional | | $1,557.58 | $1,848.33 | $2,598.56 |