- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,235.71 / $2,533.80 / $3,251.94
| Facility | | $2,235.71 | $2,533.80 | $3,251.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.27 / $1,436.27 / $1,436.27
| Professional | | $1,436.27 | $1,436.27 | $1,436.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.94 / $3,251.94 / $3,251.94
| Professional | | $3,251.94 | $3,251.94 | $3,251.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.95 / $2,709.95 / $2,837.64
| Professional | | $2,709.95 | $2,709.95 | $2,837.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,980.95 / $3,251.94 / $3,793.93
| Professional | | $2,980.95 | $3,251.94 | $3,793.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.94 / $3,251.94 / $4,064.93
| Professional | | $3,251.94 | $3,251.94 | $4,064.93 |