- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,981.07
| Facility | | $2,454.71 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,344.23
| Professional | | $1,318.26 | $1,862.09 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $1,584.89
| Professional | | $831.76 | $1,174.90 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,884.03
| Professional | | $2,454.71 | $2,454.71 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $2,344.23
| Professional | | $1,318.26 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,454.71 / $3,548.13
| Professional | | $1,445.44 | $2,454.71 | $3,548.13 |