- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,451.08 / $3,911.23 / $5,019.76
| Facility | | $3,451.08 | $3,911.23 | $5,019.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.06 / $2,217.06 / $2,217.06
| Professional | | $2,217.06 | $2,217.06 | $2,217.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,019.76 / $5,019.76 / $5,019.76
| Professional | | $5,019.76 | $5,019.76 | $5,019.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,183.13 / $4,183.13 / $5,228.91
| Professional | | $4,183.13 | $4,183.13 | $5,228.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,601.43 / $5,019.76 / $5,856.38
| Professional | | $4,601.43 | $5,019.76 | $5,856.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,183.13 / $6,274.70 / $6,274.70
| Professional | | $4,183.13 | $6,274.70 | $6,274.70 |