- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $5,888.44
| Facility | | $3,715.35 | $3,715.35 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $3,548.13
| Professional | | $1,949.84 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $1,659.59 / $2,398.83
| Professional | | $56.23 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,365.16
| Professional | | $3,715.35 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $3,548.13
| Professional | | $1,995.26 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,715.35 / $5,370.32
| Professional | | $2,187.76 | $3,715.35 | $5,370.32 |