- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,211.30 / $2,211.30 / $3,393.00
| Facility | | $2,211.30 | $2,211.30 | $3,393.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.00 / $1,702.35 / $2,211.30
| Professional | | $1,053.00 | $1,702.35 | $2,211.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,267.50 / $1,470.30 / $3,148.47
| Facility | | $1,267.50 | $1,470.30 | $3,148.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.50 / $1,579.50 / $1,579.50
| Facility | | $1,579.50 | $1,579.50 | $1,579.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $1,950.00
| Professional | | $737.10 | $1,053.00 | $1,950.00 |