- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,608.75 / $1,823.25 / $2,340.00
| Facility | | $1,608.75 | $1,823.25 | $2,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.15 / $930.15 / $930.15
| Professional | | $930.15 | $930.15 | $930.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.00 / $2,340.00 / $2,340.00
| Professional | | $2,340.00 | $2,340.00 | $2,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.00 / $2,041.88 / $2,437.50
| Professional | | $1,950.00 | $2,041.88 | $2,437.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.00 / $2,340.00 / $2,730.00
| Professional | | $2,145.00 | $2,340.00 | $2,730.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.00 / $2,340.00 / $2,632.50
| Professional | | $1,755.00 | $2,340.00 | $2,632.50 |