- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,584.89 / $3,715.35
| Professional | | $1,258.93 | $1,584.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $2,951.21
| Professional | | $1,230.27 | $1,995.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $3,090.30
| Professional | | $1,548.82 | $1,949.84 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $3,467.37
| Professional | | $1,548.82 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $3,715.35
| Professional | | $1,258.93 | $1,737.80 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,754.23
| Professional | | $1,202.26 | $1,778.28 | $2,754.23 |