- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.03 / $1,773.70 / $2,276.40
| Facility | | $1,565.03 | $1,773.70 | $2,276.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.41 / $1,005.41 / $1,005.41
| Professional | | $1,005.41 | $1,005.41 | $1,005.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.40 / $2,276.40 / $2,276.40
| Professional | | $2,276.40 | $2,276.40 | $2,276.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.75 / $2,143.61 / $2,371.25
| Professional | | $1,787.75 | $2,143.61 | $2,371.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.69 / $2,276.40 / $2,655.80
| Professional | | $2,086.69 | $2,276.40 | $2,655.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.00 / $2,276.40 / $2,845.50
| Professional | | $1,897.00 | $2,276.40 | $2,845.50 |