- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,089.30
| Facility | | $1,445.44 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $2,187.76
| Professional | | $954.99 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,041.74 / $2,187.76
| Professional | | $1,737.80 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,089.30 / $2,630.27
| Professional | | $1,905.46 | $2,089.30 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,737.80 / $2,630.27
| Professional | | $870.96 | $1,737.80 | $2,630.27 |