- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $3,890.45
| Facility | | $2,691.53 | $3,235.94 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,754.23 / $4,073.80
| Professional | | $1,778.28 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,801.89 / $4,073.80
| Professional | | $3,235.94 | $3,801.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,890.45 / $4,897.79
| Professional | | $3,548.13 | $3,890.45 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,235.94 / $4,897.79
| Professional | | $1,621.81 | $3,235.94 | $4,897.79 |