- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,437.98 / $3,437.98 / $7,305.71
| Facility | | $3,437.98 | $3,437.98 | $7,305.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.77 / $2,784.77 / $2,784.77
| Professional | | $2,784.77 | $2,784.77 | $2,784.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.33 / $325.33 / $2,234.67
| Professional | | $325.33 | $325.33 | $2,234.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,437.98 / $3,437.98 / $3,472.36
| Professional | | $3,437.98 | $3,437.98 | $3,472.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,437.98 / $3,437.98 / $5,569.53
| Facility | | $3,437.98 | $3,437.98 | $5,569.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.77 / $2,784.77 / $3,437.98
| Professional | | $2,784.77 | $2,784.77 | $3,437.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.37 / $2,062.79 / $5,156.97
| Professional | | $1,753.37 | $2,062.79 | $5,156.97 |