- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.16 / $1,742.11 / $2,235.86
| Facility | | $1,537.16 | $1,742.11 | $2,235.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.51 / $987.51 / $987.51
| Professional | | $987.51 | $987.51 | $987.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.86 / $2,235.86 / $2,235.86
| Professional | | $2,235.86 | $2,235.86 | $2,235.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.22 / $1,951.01 / $2,329.03
| Professional | | $1,863.22 | $1,951.01 | $2,329.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.54 / $2,235.86 / $2,608.51
| Professional | | $2,049.54 | $2,235.86 | $2,608.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.22 / $2,235.86 / $2,794.83
| Professional | | $1,863.22 | $2,235.86 | $2,794.83 |