- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $2,290.87
| Facility | | $1,548.82 | $1,862.09 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,398.83
| Professional | | $1,023.29 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $2,344.23
| Professional | | $1,905.46 | $2,238.72 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,290.87 / $2,818.38
| Professional | | $2,089.30 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,905.46 / $2,818.38
| Professional | | $954.99 | $1,905.46 | $2,818.38 |