- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,303.00 / $2,303.00 / $2,303.00
| Facility | | $2,303.00 | $2,303.00 | $2,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.93 / $1,921.24 / $2,030.07
| Professional | | $1,803.93 | $1,921.24 | $2,030.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.00 / $2,076.42 / $2,442.85
| Professional | | $1,710.00 | $2,076.42 | $2,442.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.73 / $2,490.73 / $2,984.18
| Professional | | $2,490.73 | $2,490.73 | $2,984.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,714.47 / $1,968.36 / $2,218.71
| Facility | | $1,714.47 | $1,968.36 | $2,218.71 |