- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.75 / $4,380.52 / $7,580.47
| Facility | | $3,106.75 | $4,380.52 | $7,580.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,521.94 / $3,033.65 / $3,106.75
| Professional | | $2,521.94 | $3,033.65 | $3,106.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,033.65 / $8,702.00 / $13,785.00
| Facility | | $3,033.65 | $8,702.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,890.00 / $3,049.10 / $3,049.10
| Professional | | $2,890.00 | $3,049.10 | $3,049.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,728.10
| Professional | | $3,045.83 | $3,045.83 | $3,728.10 |