- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,459.27 / $2,459.27 / $2,459.27
| Professional | | $2,459.27 | $2,459.27 | $2,459.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.64 / $1,518.16 / $1,771.18
| Professional | | $1,391.64 | $1,518.16 | $1,771.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.40 / $1,830.95 / $7,050.64
| Professional | | $1,110.40 | $1,830.95 | $7,050.64 |