- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,408.67 / $2,729.83 / $3,503.52
| Facility | | $2,408.67 | $2,729.83 | $3,503.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.39 / $1,547.39 / $1,547.39
| Professional | | $1,547.39 | $1,547.39 | $1,547.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,503.52 / $3,503.52 / $3,503.52
| Professional | | $3,503.52 | $3,503.52 | $3,503.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,751.45 / $3,299.15 / $3,649.50
| Professional | | $2,751.45 | $3,299.15 | $3,649.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,211.56 / $3,503.52 / $4,087.44
| Professional | | $3,211.56 | $3,503.52 | $4,087.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,503.52 / $4,379.39
| Professional | | $2,919.60 | $3,503.52 | $4,379.39 |