- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $4,593.68 / $5,095.72
| Facility | | $2,510.21 | $4,593.68 | $5,095.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.07 / $4,593.68 / $5,095.72
| Professional | | $1,983.07 | $4,593.68 | $5,095.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.66 / $344.66 / $344.66
| Facility | | $344.66 | $344.66 | $344.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.66 / $344.66 / $344.66
| Professional | | $344.66 | $344.66 | $344.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $1,713.22 / $2,115.69
| Facility | | $1,631.64 | $1,713.22 | $2,115.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $4,741.50
| Professional | | $1,054.29 | $1,506.13 | $4,741.50 |