- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,318.51 / $5,318.51 / $5,318.51
| Facility | | $5,318.51 | $5,318.51 | $5,318.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.22 / $701.26 / $784.76
| Professional | | $541.22 | $701.26 | $784.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,501.62 / $4,863.32 / $5,384.23
| Facility | | $4,501.62 | $4,863.32 | $5,384.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.73 / $1,270.40 / $2,130.87
| Professional | | $1,077.73 | $1,270.40 | $2,130.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.15 / $1,066.50 / $1,407.13
| Professional | | $648.15 | $1,066.50 | $1,407.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.15 / $933.09 / $1,407.13
| Professional | | $651.15 | $933.09 | $1,407.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.09 / $883.79 / $2,569.25
| Professional | | $788.09 | $883.79 | $2,569.25 |