- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,253.22 / $1,420.32 / $1,822.87
| Facility | | $1,253.22 | $1,420.32 | $1,822.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.10 / $805.10 / $805.10
| Professional | | $805.10 | $805.10 | $805.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.87 / $1,822.87 / $1,822.87
| Professional | | $1,822.87 | $1,822.87 | $1,822.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.06 / $1,590.64 / $1,898.83
| Professional | | $1,519.06 | $1,590.64 | $1,898.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.97 / $1,822.87 / $2,126.67
| Professional | | $1,670.97 | $1,822.87 | $2,126.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.06 / $1,822.87 / $2,278.59
| Professional | | $1,519.06 | $1,822.87 | $2,278.59 |