- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.83 / $6,156.11 / $8,071.08
| Facility | | $1,174.83 | $6,156.11 | $8,071.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.83 / $1,174.83 / $1,174.83
| Professional | | $1,174.83 | $1,174.83 | $1,174.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.76 / $1,147.56 / $3,596.75
| Facility | | $1,115.76 | $1,147.56 | $3,596.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.44 / $1,566.44 / $1,566.44
| Professional | | $1,566.44 | $1,566.44 | $1,566.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,501.18 / $1,566.44
| Facility | | $1,305.36 | $1,501.18 | $1,566.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,502.13 / $1,951.20
| Professional | | $1,305.36 | $1,502.13 | $1,951.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.26 / $548.26 / $783.22
| Professional | | $548.26 | $548.26 | $783.22 |