- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,923.32 / $1,923.32 / $1,923.32
| Facility | | $1,923.32 | $1,923.32 | $1,923.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.18 / $1,923.32 / $2,988.99
| Professional | | $1,374.18 | $1,923.32 | $2,988.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,633.00 / $3,700.00 / $3,700.00
| Professional | | $3,633.00 | $3,700.00 | $3,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $1,545.00
| Professional | | $1,275.00 | $1,275.00 | $1,545.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.56 / $2,641.72 / $3,302.04
| Professional | | $1,217.56 | $2,641.72 | $3,302.04 |