- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.90 / $1,179.90 / $2,066.32
| Professional | | $1,179.90 | $1,179.90 | $2,066.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,304.48 / $2,304.48 / $2,304.48
| Facility | | $2,304.48 | $2,304.48 | $2,304.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.48 / $2,304.48 / $2,304.48
| Professional | | $2,304.48 | $2,304.48 | $2,304.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $2,549.92
| Facility | | $1,800.00 | $1,800.00 | $2,549.92 |
- 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
- $938.59 / $1,156.48 / $1,600.25
| Professional | | $938.59 | $1,156.48 | $1,600.25 |