- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.47 / $1,091.47 / $1,091.47
| Facility | | $1,091.47 | $1,091.47 | $1,091.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.12 / $996.79 / $1,096.48
| Professional | | $912.12 | $996.79 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.79 / $2,466.09 / $2,916.75
| Professional | | $2,260.79 | $2,466.09 | $2,916.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.92 / $2,531.50 / $3,269.06
| Professional | | $1,391.92 | $2,531.50 | $3,269.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.47 / $1,558.98 / $3,274.41
| Facility | | $1,091.47 | $1,558.98 | $3,274.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.21 / $2,075.46 / $2,752.87
| Professional | | $1,200.21 | $2,075.46 | $2,752.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,250.33 / $1,250.33 / $1,250.33
| Facility | | $1,250.33 | $1,250.33 | $1,250.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.76 / $2,210.58 / $2,752.87
| Professional | | $1,192.76 | $2,210.58 | $2,752.87 |