- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.00 / $3,655.00 / $5,117.00
| Facility | | $3,655.00 | $3,655.00 | $5,117.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,655.00 / $3,655.00 / $3,655.00
| Professional | | $3,655.00 | $3,655.00 | $3,655.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,175.15 / $2,552.17 / $3,117.72
| Facility | | $2,175.15 | $2,552.17 | $3,117.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,117.72 / $3,117.72 / $3,180.07
| Professional | | $3,117.72 | $3,117.72 | $3,180.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,984.91 / $3,045.83 / $4,099.05
| Professional | | $2,984.91 | $3,045.83 | $4,099.05 |