- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,878.80 / $11,878.80 / $11,878.80
| Facility | | $11,878.80 | $11,878.80 | $11,878.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,924.00 / $2,924.00 / $3,106.75
| Professional | | $2,924.00 | $2,924.00 | $3,106.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.75 / $3,228.58 / $3,411.33
| Facility | | $3,106.75 | $3,228.58 | $3,411.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,289.50 / $3,289.50 / $3,289.50
| Professional | | $3,289.50 | $3,289.50 | $3,289.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,045.83
| Professional | | $3,045.83 | $3,045.83 | $3,045.83 |