- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,866.00 / $2,016.55 / $2,016.55
| Facility | | $1,866.00 | $2,016.55 | $2,016.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.55 / $1,825.83 / $2,036.46
| Professional | | $1,773.55 | $1,825.83 | $2,036.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.25 / $2,373.25 / $2,984.18
| Professional | | $2,373.25 | $2,373.25 | $2,984.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,799.52 / $1,880.60 / $2,337.06
| Facility | | $1,799.52 | $1,880.60 | $2,337.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $2,000.00 / $3,900.00
| Professional | | $1,500.00 | $2,000.00 | $3,900.00 |