- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $2,344.23
| Facility | | $1,621.81 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $1,698.24
| Professional | | $1,258.93 | $1,621.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $2,454.71
| Professional | | $1,949.84 | $2,290.87 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,344.23 / $2,951.21
| Professional | | $2,137.96 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,949.84 / $2,630.27
| Professional | | $977.24 | $1,949.84 | $2,630.27 |