- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.65 / $1,655.40 / $2,124.58
| Facility | | $1,460.65 | $1,655.40 | $2,124.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.36 / $938.36 / $938.36
| Professional | | $938.36 | $938.36 | $938.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,124.58 / $2,124.58 / $2,124.58
| Professional | | $2,124.58 | $2,124.58 | $2,124.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.48 / $1,853.91 / $2,213.10
| Professional | | $1,770.48 | $1,853.91 | $2,213.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.53 / $2,124.58 / $2,478.67
| Professional | | $1,947.53 | $2,124.58 | $2,478.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.48 / $2,124.58 / $2,655.72
| Professional | | $1,770.48 | $2,124.58 | $2,655.72 |