- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.56 / $4,480.85 / $4,970.58
| Facility | | $2,448.56 | $4,480.85 | $4,970.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.36 / $2,693.42 / $4,970.58
| Professional | | $1,934.36 | $2,693.42 | $4,970.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.89 / $3,019.89 / $3,019.89
| Facility | | $3,019.89 | $3,019.89 | $3,019.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.89 / $3,019.89 / $3,019.89
| Professional | | $3,019.89 | $3,019.89 | $3,019.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.56 / $1,671.14 / $2,053.11
| Facility | | $1,591.56 | $1,671.14 | $2,053.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.41 / $1,649.27 / $3,517.21
| Professional | | $939.41 | $1,649.27 | $3,517.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.05 / $1,028.40 / $1,591.56
| Professional | | $301.05 | $1,028.40 | $1,591.56 |