- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,458.40 / $1,458.40 / $9,500.00
| Facility | | $1,458.40 | $1,458.40 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.40 / $2,016.27 / $2,111.67
| Professional | | $1,322.40 | $2,016.27 | $2,111.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,458.40 / $2,722.36 / $3,732.07
| Facility | | $1,458.40 | $2,722.36 | $3,732.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.52 / $4,008.47 / $5,650.99
| Professional | | $2,302.52 | $4,008.47 | $5,650.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.52 / $3,592.99 / $4,715.99
| Professional | | $2,302.52 | $3,592.99 | $4,715.99 |