- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,182.36 / $5,313.67 / $5,839.20
| Facility | | $3,182.36 | $5,313.67 | $5,839.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.48 / $5,313.67 / $5,839.20
| Professional | | $2,306.48 | $5,313.67 | $5,839.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,940.00 / $2,940.00 / $3,234.00
| Facility | | $2,940.00 | $2,940.00 | $3,234.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Professional | | $2,919.60 | $2,919.60 | $2,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $4,817.05
| Professional | | $1,226.23 | $1,751.76 | $4,817.05 |