- 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
- $1,914.56 / $1,914.56 / $2,209.76
| Professional | | $1,914.56 | $1,914.56 | $2,209.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.78 / $2,267.76 / $2,645.72
| Professional | | $2,078.78 | $2,267.76 | $2,645.72 |
- 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
- $2,125.03 / $2,734.98 / $3,470.13
| Professional | | $2,125.03 | $2,734.98 | $3,470.13 |