- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,565.33
| Professional | | $1,448.30 | $1,448.30 | $2,565.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,800.00 / $3,800.00 / $4,180.00
| Facility | | $3,800.00 | $3,800.00 | $4,180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,182.50 / $3,182.50 / $3,800.00
| Professional | | $3,182.50 | $3,182.50 | $3,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $2,237.34 / $2,461.07
| Facility | | $1,448.30 | $2,237.34 | $2,461.07 |