- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,761.00 / $1,761.00 / $1,761.00
| Facility | | $1,761.00 | $1,761.00 | $1,761.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.87 / $1,527.96 / $1,620.89
| Professional | | $1,376.87 | $1,527.96 | $1,620.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.40 / $1,654.34 / $1,946.28
| Professional | | $1,362.40 | $1,654.34 | $1,946.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,095.62 / $2,095.62 / $2,510.79
| Professional | | $2,095.62 | $2,095.62 | $2,510.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.04 / $1,567.13 / $1,864.90
| Facility | | $1,375.04 | $1,567.13 | $1,864.90 |