- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.84 / $8,815.78 / $14,580.00
| Facility | | $1,053.84 | $8,815.78 | $14,580.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.87 / $1,029.07 / $1,053.85
| Professional | | $991.87 | $1,029.07 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.20 / $1,033.20 / $1,033.20
| Professional | | $1,033.20 | $1,033.20 | $1,033.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Facility | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Professional | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.88 / $1,033.20 / $1,177.84
| Professional | | $898.88 | $1,033.20 | $1,177.84 |