- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,784.56 / $3,897.53 / $5,353.35
| Facility | | $3,784.56 | $3,897.53 | $5,353.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.05 / $2,947.82 / $3,897.53
| Professional | | $2,947.05 | $2,947.82 | $3,897.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,954.02 / $4,086.50 / $4,441.88
| Professional | | $3,954.02 | $4,086.50 | $4,441.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $6,354.61
| Facility | | $422.50 | $422.50 | $6,354.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $4,550.34 / $8,385.94
| Professional | | $422.50 | $4,550.34 | $8,385.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.19 / $558.19 / $558.19
| Professional | | $558.19 | $558.19 | $558.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,667.78 / $2,872.59 / $5,109.60
| Professional | | $2,667.78 | $2,872.59 | $5,109.60 |