- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,581.63 / $2,877.05 / $3,496.64
| Facility | | $2,581.63 | $2,877.05 | $3,496.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,581.63 / $2,581.63 / $2,581.63
| Professional | | $2,581.63 | $2,581.63 | $2,581.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $2,643.84
| Professional | | $2,643.84 | $2,643.84 | $2,643.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,203.26
| Professional | | $45.00 | $45.00 | $3,203.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,954.88 / $3,641.00 / $3,832.48
| Professional | | $2,954.88 | $3,641.00 | $3,832.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Professional | | $2,592.00 | $2,592.00 | $2,592.00 |