- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,848.00 / $1,848.00 / $1,848.00
| Facility | | $1,848.00 | $1,848.00 | $1,848.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $646.13 / $807.66
| Professional | | $360.74 | $646.13 | $807.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.89 / $1,989.95 / $2,485.44
| Professional | | $1,620.89 | $1,989.95 | $2,485.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.92 / $1,032.19 / $1,744.40
| Facility | | $850.92 | $1,032.19 | $1,744.40 |