- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,231.85 / $5,231.85 / $5,231.85
| Facility | | $5,231.85 | $5,231.85 | $5,231.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.00 / $1,898.00 / $1,898.00
| Professional | | $1,898.00 | $1,898.00 | $1,898.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.57 / $1,133.57 / $1,133.57
| Facility | | $1,133.57 | $1,133.57 | $1,133.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,703.12 / $2,842.64 / $2,842.64
| Professional | | $2,703.12 | $2,842.64 | $2,842.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.57 / $1,473.95 / $1,743.95
| Facility | | $1,133.57 | $1,473.95 | $1,743.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,839.87 / $2,110.17 / $2,424.09
| Professional | | $1,839.87 | $2,110.17 | $2,424.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.32 / $491.32 / $701.88
| Professional | | $491.32 | $491.32 | $701.88 |