- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,381.59 / $4,381.59 / $4,700.69
| Facility | | $4,381.59 | $4,381.59 | $4,700.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.80 / $4,087.56 / $5,219.76
| Professional | | $3,133.80 | $4,087.56 | $5,219.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,761.34 / $2,362.30 / $3,074.62
| Facility | | $1,761.34 | $2,362.30 | $3,074.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,100.85 / $4,969.71 / $5,401.04
| Professional | | $4,100.85 | $4,969.71 | $5,401.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Facility | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.89 / $5,106.14 / $7,489.87
| Professional | | $616.89 | $5,106.14 | $7,489.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.48 / $2,440.62 / $4,502.00
| Professional | | $1,946.48 | $2,440.62 | $4,502.00 |