- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,712.54 / $1,940.87 / $2,490.96
| Facility | | $1,712.54 | $1,940.87 | $2,490.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.96 / $2,490.96 / $2,490.96
| Professional | | $2,490.96 | $2,490.96 | $2,490.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.57 / $2,173.61 / $2,594.75
| Professional | | $1,847.57 | $2,173.61 | $2,594.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,490.96 / $3,113.70
| Professional | | $2,075.80 | $2,490.96 | $3,113.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $2,490.96 / $3,113.70
| Professional | | $871.84 | $2,490.96 | $3,113.70 |