- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,816.34 / $2,058.51 / $2,641.94
| Facility | | $1,816.34 | $2,058.51 | $2,641.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.94 / $2,641.94 / $2,641.94
| Professional | | $2,641.94 | $2,641.94 | $2,641.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.56 / $2,305.36 / $2,752.03
| Professional | | $1,959.56 | $2,305.36 | $2,752.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,641.94 / $3,302.43
| Professional | | $2,201.62 | $2,641.94 | $3,302.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,641.94 / $2,641.94
| Professional | | $2,201.62 | $2,641.94 | $2,641.94 |