- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $2,691.53
| Facility | | $1,819.70 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $2,137.96
| Professional | | $1,202.26 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,754.23
| Professional | | $2,238.72 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,311.31
| Professional | | $2,238.72 | $2,691.53 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,238.72 / $3,311.31
| Professional | | $933.25 | $2,238.72 | $3,311.31 |