- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,008.88 / $2,276.73 / $2,922.00
| Facility | | $2,008.88 | $2,276.73 | $2,922.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.55 / $1,290.55 / $1,290.55
| Professional | | $1,290.55 | $1,290.55 | $1,290.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,922.00 / $2,922.00 / $2,922.00
| Professional | | $2,922.00 | $2,922.00 | $2,922.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.77 / $2,549.73 / $3,043.75
| Professional | | $2,294.77 | $2,549.73 | $3,043.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,678.50 / $2,922.00 / $3,409.00
| Professional | | $2,678.50 | $2,922.00 | $3,409.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.00 / $2,922.00 / $3,652.50
| Professional | | $2,435.00 | $2,922.00 | $3,652.50 |