- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.92 / $1,702.92 / $2,982.27
| Professional | | $1,702.92 | $1,702.92 | $2,982.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,326.01 / $3,326.01 / $3,326.01
| Facility | | $3,326.01 | $3,326.01 | $3,326.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,326.01 / $3,326.01 / $3,326.01
| Professional | | $3,326.01 | $3,326.01 | $3,326.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,400.00 / $4,449.35
| Facility | | $2,400.00 | $2,400.00 | $4,449.35 |
- 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
- $1,482.08 / $1,639.81 / $2,526.89
| Professional | | $1,482.08 | $1,639.81 | $2,526.89 |