- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,017.82 / $5,017.82 / $5,191.70
| Facility | | $5,017.82 | $5,017.82 | $5,191.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,980.57 / $4,761.22 / $6,149.63
| Professional | | $3,980.57 | $4,761.22 | $6,149.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.77 / $1,340.77 / $1,340.77
| Facility | | $1,340.77 | $1,340.77 | $1,340.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,388.00 / $5,021.27 / $5,781.54
| Professional | | $4,388.00 | $5,021.27 | $5,781.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.96 / $5,470.13 / $6,026.40
| Professional | | $651.96 | $5,470.13 | $6,026.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,287.40 / $2,960.16 / $5,079.09
| Professional | | $2,287.40 | $2,960.16 | $5,079.09 |