- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,467.37
| Facility | | $2,398.83 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $2,818.38
| Professional | | $1,584.89 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,467.37 / $3,630.78
| Professional | | $2,884.03 | $3,467.37 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,467.37 / $4,365.16
| Professional | | $3,235.94 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,884.03 / $4,365.16
| Professional | | $1,445.44 | $2,884.03 | $4,365.16 |