- 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
- $1,824.79 / $1,824.79 / $1,824.79
| Professional | | $1,824.79 | $1,824.79 | $1,824.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,308.60 / $2,842.53 / $3,230.15
| Professional | | $2,308.60 | $2,842.53 | $3,230.15 |
- 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
- $2,288.13 / $3,120.68 / $3,227.74
| Professional | | $2,288.13 | $3,120.68 | $3,227.74 |