- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,070.92 / $2,347.05 / $3,012.25
| Facility | | $2,070.92 | $2,347.05 | $3,012.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.41 / $1,330.41 / $1,330.41
| Professional | | $1,330.41 | $1,330.41 | $1,330.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.25 / $3,012.25 / $3,012.25
| Professional | | $3,012.25 | $3,012.25 | $3,012.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,628.49 / $3,137.76
| Professional | | $2,510.21 | $2,628.49 | $3,137.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.23 / $3,012.25 / $3,514.29
| Professional | | $2,761.23 | $3,012.25 | $3,514.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $3,012.25 / $3,765.32
| Professional | | $2,510.21 | $3,012.25 | $3,765.32 |