- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $2,754.23
| Facility | | $1,862.09 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,884.03
| Professional | | $1,230.27 | $1,584.89 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,818.38
| Professional | | $2,290.87 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $3,388.44
| Professional | | $2,511.89 | $2,754.23 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,290.87 / $3,388.44
| Professional | | $1,148.15 | $2,290.87 | $3,388.44 |