- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $3,801.89
| Facility | | $2,630.27 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $3,090.30
| Professional | | $478.63 | $478.63 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Professional | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $3,981.07
| Professional | | $3,162.28 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $4,786.30
| Professional | | $3,467.37 | $3,801.89 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,162.28 / $4,786.30
| Professional | | $1,584.89 | $3,162.28 | $4,786.30 |