- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,606.52 / $2,954.06 / $3,791.30
| Facility | | $2,606.52 | $2,954.06 | $3,791.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $477.00
| Professional | | $477.00 | $477.00 | $477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,791.30 / $3,791.30 / $3,791.30
| Professional | | $3,791.30 | $3,791.30 | $3,791.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,977.46 / $3,308.29 / $3,949.28
| Professional | | $2,977.46 | $3,308.29 | $3,949.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,475.36 / $3,791.30 / $4,423.18
| Professional | | $3,475.36 | $3,791.30 | $4,423.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,791.30 / $4,739.13
| Professional | | $3,159.42 | $3,791.30 | $4,739.13 |