- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,139.46 / $5,970.77 / $7,828.09
| Facility | | $1,139.46 | $5,970.77 | $7,828.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.46 / $1,139.46 / $1,139.46
| Professional | | $1,139.46 | $1,139.46 | $1,139.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.18 / $1,113.02 / $3,488.49
| Facility | | $1,082.18 | $1,113.02 | $3,488.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.28 / $1,519.28 / $1,519.28
| Professional | | $1,519.28 | $1,519.28 | $1,519.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.05 / $1,455.98 / $1,519.28
| Facility | | $1,304.05 | $1,455.98 | $1,519.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.90 / $1,453.87 / $1,755.92
| Professional | | $1,310.90 | $1,453.87 | $1,755.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $531.75 / $759.64
| Professional | | $531.75 | $531.75 | $759.64 |