- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,878.94 / $3,262.80 / $4,187.56
| Facility | | $2,878.94 | $3,262.80 | $4,187.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.50 / $1,849.50 / $1,849.50
| Professional | | $1,849.50 | $1,849.50 | $1,849.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,187.56 / $4,187.56 / $4,187.56
| Professional | | $4,187.56 | $4,187.56 | $4,187.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,288.65 / $3,943.28 / $4,362.04
| Professional | | $3,288.65 | $3,943.28 | $4,362.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,838.59 / $4,187.56 / $4,885.47
| Professional | | $3,838.59 | $4,187.56 | $4,885.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,489.63 / $4,187.56 / $5,234.45
| Professional | | $3,489.63 | $4,187.56 | $5,234.45 |