- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,312.55 / $1,312.55 / $2,050.86
| Facility | | $1,312.55 | $1,312.55 | $2,050.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.09 / $1,908.35 / $2,050.86
| Professional | | $1,232.09 | $1,908.35 | $2,050.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.98 / $1,814.98 / $1,814.98
| Professional | | $1,814.98 | $1,814.98 | $1,814.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Facility | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.00 / $1,530.00 / $1,800.00
| Professional | | $1,530.00 | $1,530.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.31 / $1,168.47 / $1,848.22
| Professional | | $692.31 | $1,168.47 | $1,848.22 |