- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $3,311.31
| Facility | | $2,290.87 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,137.96 / $2,691.53
| Professional | | $457.09 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $3,467.37
| Professional | | $2,754.23 | $3,235.94 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,311.31 / $4,168.69
| Professional | | $3,019.95 | $3,311.31 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,754.23 / $4,168.69
| Professional | | $1,380.38 | $2,754.23 | $4,168.69 |