- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,678.70 / $3,678.70 / $6,090.00
| Facility | | $3,678.70 | $3,678.70 | $6,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.76 / $2,832.01 / $3,678.70
| Professional | | $1,751.76 | $2,832.01 | $3,678.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,275.00 / $4,364.80 / $4,514.85
| Facility | | $2,275.00 | $4,364.80 | $4,514.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,627.64 / $2,627.64 / $2,627.64
| Facility | | $2,627.64 | $2,627.64 | $2,627.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |