- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,801.89 / $4,677.35
| Facility | | $3,162.28 | $3,801.89 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,311.31 / $4,897.79
| Professional | | $2,089.30 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,248.07 / $5,888.44
| Professional | | $4,265.80 | $5,248.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,677.35 / $5,754.40
| Professional | | $4,265.80 | $4,677.35 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,890.45 / $5,754.40
| Professional | | $1,949.84 | $3,890.45 | $5,754.40 |