- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $2,570.40
| Facility | | $1,737.80 | $2,089.30 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $2,691.53
| Professional | | $1,148.15 | $1,819.70 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $2,630.27
| Professional | | $2,137.96 | $2,511.89 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $3,162.28
| Professional | | $2,344.23 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,137.96 / $3,162.28
| Professional | | $1,071.52 | $2,137.96 | $3,162.28 |