- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.59 / $1,043.59 / $2,033.49
| Facility | | $1,043.59 | $1,043.59 | $2,033.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.20 / $1,043.59 / $1,401.72
| Professional | | $828.20 | $1,043.59 | $1,401.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.39 / $1,277.86 / $2,273.76
| Professional | | $936.39 | $1,277.86 | $2,273.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.66 / $1,531.55 / $2,207.98
| Professional | | $1,148.66 | $1,531.55 | $2,207.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.16 / $1,087.30 / $1,917.74
| Professional | | $748.16 | $1,087.30 | $1,917.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.53 / $1,010.95 / $1,939.69
| Professional | | $741.53 | $1,010.95 | $1,939.69 |