- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,124.09 / $2,407.30 / $3,089.58
| Facility | | $2,124.09 | $2,407.30 | $3,089.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.56 / $1,364.56 / $1,364.56
| Professional | | $1,364.56 | $1,364.56 | $1,364.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,089.58 / $3,089.58 / $3,089.58
| Professional | | $3,089.58 | $3,089.58 | $3,089.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,695.97 / $3,218.31
| Professional | | $2,574.65 | $2,695.97 | $3,218.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.12 / $3,089.58 / $3,604.51
| Professional | | $2,832.12 | $3,089.58 | $3,604.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $3,089.58 / $3,861.98
| Professional | | $2,574.65 | $3,089.58 | $3,861.98 |