- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,447.88 / $1,640.93 / $2,106.00
| Facility | | $1,447.88 | $1,640.93 | $2,106.00 |
- 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
- $2,106.00 / $2,106.00 / $2,106.00
| Professional | | $2,106.00 | $2,106.00 | $2,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.00 / $1,837.70 / $2,193.75
| Professional | | $1,755.00 | $1,837.70 | $2,193.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.50 / $2,106.00 / $2,457.00
| Professional | | $1,930.50 | $2,106.00 | $2,457.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.00 / $2,106.00 / $2,632.50
| Professional | | $1,755.00 | $2,106.00 | $2,632.50 |