- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $3,162.28
| Facility | | $2,187.76 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $3,311.31
| Professional | | $1,445.44 | $2,290.87 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $3,311.31
| Professional | | $2,630.27 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,162.28 / $3,981.07
| Professional | | $2,884.03 | $3,162.28 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,630.27 / $3,981.07
| Professional | | $1,318.26 | $2,630.27 | $3,981.07 |