- 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
- $3,625.40 / $3,625.40 / $3,625.40
| Facility | | $3,625.40 | $3,625.40 | $3,625.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,625.40 / $3,625.40 / $3,625.40
| Professional | | $3,625.40 | $3,625.40 | $3,625.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $1,713.22 / $2,598.52
| Facility | | $1,631.64 | $1,713.22 | $2,598.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.22 / $1,213.24 / $4,774.78
| Professional | | $1,143.22 | $1,213.24 | $4,774.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,549.51 / $4,648.53
| Professional | | $1,054.29 | $1,549.51 | $4,648.53 |