- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.04 / $1,725.04 / $1,725.04
| Facility | | $1,725.04 | $1,725.04 | $1,725.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,582.96 / $1,597.48
| Professional | | $1,452.25 | $1,582.96 | $1,597.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.00 / $3,000.00 / $3,000.00
| Professional | | $2,550.00 | $3,000.00 | $3,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,370.05 / $1,370.05
| Facility | | $1,370.05 | $1,370.05 | $1,370.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $2,055.07 / $2,055.07
| Professional | | $1,452.25 | $2,055.07 | $2,055.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |