- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.48 / $6,300.99 / $8,261.04
| Facility | | $1,202.48 | $6,300.99 | $8,261.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.48 / $1,202.48 / $1,202.48
| Professional | | $1,202.48 | $1,202.48 | $1,202.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.02 / $1,174.57 / $3,681.40
| Facility | | $1,142.02 | $1,174.57 | $3,681.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.31 / $1,603.31 / $1,603.31
| Professional | | $1,603.31 | $1,603.31 | $1,603.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,536.50 / $1,603.31
| Facility | | $1,336.09 | $1,536.50 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,537.36 / $1,996.97
| Professional | | $1,336.09 | $1,537.36 | $1,996.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $561.16 / $801.65
| Professional | | $561.16 | $561.16 | $801.65 |