- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $4,365.16
| Facility | | $2,951.21 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,090.30 / $4,570.88
| Professional | | $1,949.84 | $3,090.30 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,801.89 / $4,466.84
| Professional | | $3,630.78 | $3,801.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,365.16 / $5,370.32
| Professional | | $3,981.07 | $4,365.16 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,630.78 / $5,370.32
| Professional | | $1,819.70 | $3,630.78 | $5,370.32 |