- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,041.53 / $10,041.53 / $10,041.53
| Facility | | $10,041.53 | $10,041.53 | $10,041.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.80 / $1,205.05 / $1,633.35
| Professional | | $1,071.80 | $1,205.05 | $1,633.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.54 / $1,393.84 / $2,142.75
| Professional | | $1,129.54 | $1,393.84 | $2,142.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.86 / $1,628.44 / $2,294.66
| Professional | | $1,313.86 | $1,628.44 | $2,294.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.33 / $1,330.58 / $2,070.38
| Professional | | $1,195.33 | $1,330.58 | $2,070.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,041.53 / $10,041.53 / $10,041.53
| Facility | | $10,041.53 | $10,041.53 | $10,041.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.80 / $1,205.05 / $1,633.35
| Professional | | $1,071.80 | $1,205.05 | $1,633.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.74 / $1,518.28 / $1,832.41
| Professional | | $1,075.74 | $1,518.28 | $1,832.41 |