- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,063.83 / $1,063.83 / $2,016.20
| Facility | | $1,063.83 | $1,063.83 | $2,016.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.53 / $1,099.30 / $2,016.20
| Professional | | $886.53 | $1,099.30 | $2,016.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.09 / $1,361.09 / $1,361.09
| Professional | | $1,361.09 | $1,361.09 | $1,361.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.13 / $1,977.45 / $2,671.62
| Facility | | $900.13 | $1,977.45 | $2,671.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.36 / $1,270.82 / $1,897.61
| Professional | | $877.36 | $1,270.82 | $1,897.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.53 / $1,382.15 / $2,491.15
| Facility | | $886.53 | $1,382.15 | $2,491.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.40 / $1,339.94 / $5,839.98
| Professional | | $1,013.40 | $1,339.94 | $5,839.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.40 / $1,287.02 / $1,825.20
| Professional | | $1,013.40 | $1,287.02 | $1,825.20 |