- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,004.27 / $6,167.40 / $8,690.62
| Facility | | $1,004.27 | $6,167.40 | $8,690.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.27 / $1,004.27 / $1,029.06
| Professional | | $1,004.27 | $1,004.27 | $1,029.06 |
- 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
- 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
- Facility
- Modifier
- Low / Median / High Price
- $1,004.27 / $1,054.48 / $1,255.33
| Facility | | $1,004.27 | $1,054.48 | $1,255.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.20 / $1,033.20 / $4,487.04
| Professional | | $1,033.20 | $1,033.20 | $4,487.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.20 / $1,033.20 / $1,167.52
| Professional | | $1,033.20 | $1,033.20 | $1,167.52 |