- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.62 / $1,320.31 / $2,010.93
| Facility | | $1,015.62 | $1,320.31 | $2,010.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.91 / $1,015.62 / $1,015.62
| Professional | | $978.91 | $1,015.62 | $1,015.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.58 / $1,143.58 / $1,143.58
| Professional | | $1,143.58 | $1,143.58 | $1,143.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Facility | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Professional | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.46 / $5,404.40 / $5,404.40
| Facility | | $1,162.46 | $5,404.40 | $5,404.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.70 / $1,019.70 / $1,040.08
| Professional | | $1,019.70 | $1,019.70 | $1,040.08 |