- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,951.21
| Facility | | $2,041.74 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,089.30 / $3,090.30
| Professional | | $1,348.96 | $2,089.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,570.40 / $3,090.30
| Professional | | $2,454.71 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $3,715.35
| Professional | | $2,691.53 | $2,951.21 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,454.71 / $3,715.35
| Professional | | $1,230.27 | $2,454.71 | $3,715.35 |