- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $3,630.78
| Facility | | $2,454.71 | $2,951.21 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,818.38
| Professional | | $1,513.56 | $1,513.56 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $3,715.35
| Professional | | $3,019.95 | $3,548.13 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,630.78 / $4,466.84
| Professional | | $3,311.31 | $3,630.78 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,019.95 / $4,466.84
| Professional | | $1,513.56 | $3,019.95 | $4,466.84 |