- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.52 / $1,113.52 / $1,113.52
| Facility | | $1,113.52 | $1,113.52 | $1,113.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.34 / $1,113.52 / $1,638.98
| Professional | | $991.34 | $1,113.52 | $1,638.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.81 / $1,343.00 / $2,179.58
| Professional | | $964.81 | $1,343.00 | $2,179.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.35 / $1,070.47 / $1,329.71
| Professional | | $837.35 | $1,070.47 | $1,329.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.49 / $1,616.31 / $1,795.91
| Professional | | $1,197.49 | $1,616.31 | $1,795.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.20 / $1,117.20 / $1,600.21
| Professional | | $851.20 | $1,117.20 | $1,600.21 |