- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $5,844.13
| Facility | | $2,337.65 | $2,337.65 | $5,844.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,337.65
| Professional | | $2,337.65 | $2,337.65 | $2,337.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.06 / $1,028.56 / $1,519.47
| Professional | | $935.06 | $1,028.56 | $1,519.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,986.14 / $4,986.14 / $4,986.14
| Facility | | $4,986.14 | $4,986.14 | $4,986.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.65 / $2,365.73 / $2,470.46
| Professional | | $1,480.65 | $2,365.73 | $2,470.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,361.03
| Professional | | $2,337.65 | $2,337.65 | $2,361.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $5,844.13
| Facility | | $2,337.65 | $2,337.65 | $5,844.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,337.65
| Professional | | $2,337.65 | $2,337.65 | $2,337.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.20 / $1,402.59 / $4,090.89
| Professional | | $1,192.20 | $1,402.59 | $4,090.89 |