- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,880.18 / $2,130.87 / $2,734.80
| Facility | | $1,880.18 | $2,130.87 | $2,734.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.86 / $1,207.86 / $1,207.86
| Professional | | $1,207.86 | $1,207.86 | $1,207.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.80 / $2,734.80 / $2,734.80
| Professional | | $2,734.80 | $2,734.80 | $2,734.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.00 / $2,386.39 / $2,848.75
| Professional | | $2,279.00 | $2,386.39 | $2,848.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,506.90 / $2,734.80 / $3,190.60
| Professional | | $2,506.90 | $2,734.80 | $3,190.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.80 / $2,734.80 / $3,418.50
| Professional | | $2,734.80 | $2,734.80 | $3,418.50 |