- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,467.37
| Facility | | $2,398.83 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,511.89 / $3,715.35
| Professional | | $1,584.89 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $3,630.78
| Professional | | $2,951.21 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,467.37 / $4,365.16
| Professional | | $3,235.94 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,951.21 / $4,365.16
| Professional | | $1,445.44 | $2,951.21 | $4,365.16 |