- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.33 / $1,346.33 / $1,346.33
| Professional | | $1,346.33 | $1,346.33 | $1,346.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.21 / $2,972.04 / $3,662.69
| Professional | | $2,707.21 | $2,972.04 | $3,662.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.27 / $2,196.17 / $2,489.06
| Professional | | $1,647.27 | $2,196.17 | $2,489.06 |