- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,782.00 / $11,782.00 / $11,782.00
| Facility | | $11,782.00 | $11,782.00 | $11,782.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.19 / $2,900.19 / $3,081.45
| Professional | | $2,900.19 | $2,900.19 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,202.30 / $3,383.56
| Facility | | $3,081.45 | $3,202.30 | $3,383.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,262.72 / $3,262.72 / $3,262.72
| Professional | | $3,262.72 | $3,262.72 | $3,262.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.00 / $3,021.04 / $3,021.04
| Professional | | $1,375.00 | $3,021.04 | $3,021.04 |