- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.54 / $1,342.54 / $1,342.54
| Facility | | $1,208.54 | $1,342.54 | $1,342.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.54 / $1,346.70 / $3,077.32
| Professional | | $1,208.54 | $1,346.70 | $3,077.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.00 / $1,700.00 / $1,700.00
| Professional | | $1,700.00 | $1,700.00 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.12 / $2,435.12 / $2,435.12
| Professional | | $2,435.12 | $2,435.12 | $2,435.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.31 / $2,477.09 / $4,040.87
| Professional | | $1,722.31 | $2,477.09 | $4,040.87 |