- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $2,238.72
| Facility | | $1,548.82 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $2,344.23
| Professional | | $1,023.29 | $1,584.89 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $2,344.23
| Professional | | $1,862.09 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $2,818.38
| Professional | | $2,041.74 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,862.09 / $2,818.38
| Professional | | $933.25 | $1,862.09 | $2,818.38 |