- 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
- $1,713.19 / $1,713.19 / $2,028.65
| Professional | | $1,713.19 | $1,713.19 | $2,028.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.95 / $1,255.29 / $1,426.46
| Professional | | $1,010.95 | $1,255.29 | $1,426.46 |
- 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
- $2,260.60 / $3,023.01 / $3,147.61
| Professional | | $2,260.60 | $3,023.01 | $3,147.61 |