- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,287.87 / $4,292.34 / $5,623.54
| Facility | | $4,287.87 | $4,292.34 | $5,623.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,747.63 / $1,799.54
| Professional | | $1,730.32 | $1,747.63 | $1,799.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.10 / $1,737.10 / $1,837.13
| Facility | | $1,737.10 | $1,737.10 | $1,837.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.38 / $1,730.32 / $1,730.32
| Facility | | $1,632.38 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.24 / $1,730.32 / $1,926.21
| Professional | | $535.24 | $1,730.32 | $1,926.21 |