- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,186.25 / $2,477.75 / $3,180.00
| Facility | | $2,186.25 | $2,477.75 | $3,180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.50 / $1,404.50 / $1,404.50
| Professional | | $1,404.50 | $1,404.50 | $1,404.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,180.00 / $3,180.00 / $3,180.00
| Professional | | $3,180.00 | $3,180.00 | $3,180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.00 / $2,774.87 / $3,312.50
| Professional | | $2,650.00 | $2,774.87 | $3,312.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.00 / $3,180.00 / $3,710.00
| Professional | | $2,915.00 | $3,180.00 | $3,710.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.00 / $3,975.00 / $3,975.00
| Professional | | $2,650.00 | $3,975.00 | $3,975.00 |