- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,311.77 / $1,611.07 / $2,505.38
| Facility | | $1,311.77 | $1,611.07 | $2,505.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.77 / $1,696.65 / $2,863.05
| Professional | | $1,311.77 | $1,696.65 | $2,863.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.93 / $1,422.97 / $1,710.02
| Facility | | $1,307.93 | $1,422.97 | $1,710.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.06 / $1,520.02 / $1,520.02
| Professional | | $964.06 | $1,520.02 | $1,520.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,281.71 / $2,281.71 / $2,281.71
| Facility | | $2,281.71 | $2,281.71 | $2,281.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.43 / $2,392.14 / $5,362.20
| Professional | | $1,409.43 | $2,392.14 | $5,362.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.09 / $2,184.48 / $3,141.95
| Professional | | $1,361.09 | $2,184.48 | $3,141.95 |