- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,332.30 / $1,332.30 / $8,500.00
| Facility | | $1,332.30 | $1,332.30 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.30 / $1,332.30 / $1,339.30
| Professional | | $1,332.30 | $1,332.30 | $1,339.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,332.30 / $2,239.52 / $3,996.90
| Facility | | $1,332.30 | $2,239.52 | $3,996.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.14 / $3,574.45 / $4,921.81
| Professional | | $2,005.14 | $3,574.45 | $4,921.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.92 / $3,491.59 / $4,421.54
| Professional | | $1,944.92 | $3,491.59 | $4,421.54 |