- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,567.67 / $1,776.69 / $2,280.23
| Facility | | $1,567.67 | $1,776.69 | $2,280.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.11 / $1,007.11 / $1,007.11
| Professional | | $1,007.11 | $1,007.11 | $1,007.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.23 / $2,280.23 / $2,280.23
| Professional | | $2,280.23 | $2,280.23 | $2,280.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.20 / $1,900.20 / $1,989.74
| Professional | | $1,900.20 | $1,900.20 | $1,989.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.21 / $2,280.23 / $2,660.28
| Professional | | $2,090.21 | $2,280.23 | $2,660.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.20 / $2,280.23 / $2,850.30
| Professional | | $1,900.20 | $2,280.23 | $2,850.30 |