- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,792.32 / $8,792.32 / $8,792.32
| Facility | | $8,792.32 | $8,792.32 | $8,792.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.59 / $1,867.59 / $2,459.27
| Professional | | $1,867.59 | $1,867.59 | $2,459.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.79 / $2,804.91 / $3,162.90
| Facility | | $2,162.79 | $2,804.91 | $3,162.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.67 / $635.53 / $635.53
| Professional | | $584.67 | $635.53 | $635.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.92 / $1,333.47 / $2,074.88
| Professional | | $1,197.92 | $1,333.47 | $2,074.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,792.32 / $8,792.32 / $8,792.32
| Facility | | $8,792.32 | $8,792.32 | $8,792.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.59 / $1,867.59 / $2,459.27
| Professional | | $1,867.59 | $1,867.59 | $2,459.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.47 / $1,596.74 / $1,927.10
| Professional | | $1,333.47 | $1,596.74 | $1,927.10 |