- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,438.76 / $1,630.59 / $2,092.73
| Facility | | $1,438.76 | $1,630.59 | $2,092.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.73 / $2,092.73 / $2,092.73
| Professional | | $2,092.73 | $2,092.73 | $2,092.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.69 / $2,069.19 / $2,288.94
| Professional | | $1,725.69 | $2,069.19 | $2,288.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.35 / $2,092.73 / $2,441.53
| Professional | | $1,918.35 | $2,092.73 | $2,441.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.98 / $1,676.97 / $2,092.73
| Professional | | $1,117.98 | $1,676.97 | $2,092.73 |