- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,467.37 / $4,168.69
| Facility | | $2,884.03 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,019.95 / $4,365.16
| Professional | | $1,905.46 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Professional | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,168.69 / $4,365.16
| Professional | | $3,467.37 | $4,168.69 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,168.69 / $5,248.07
| Professional | | $3,890.45 | $4,168.69 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,467.37 / $5,248.07
| Professional | | $1,737.80 | $3,467.37 | $5,248.07 |