- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.72 / $1,005.72 / $1,005.72
| Facility | | $1,005.72 | $1,005.72 | $1,005.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.13 / $1,005.72 / $1,095.17
| Professional | | $880.13 | $1,005.72 | $1,095.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.30 / $405.23 / $486.76
| Professional | | $372.30 | $405.23 | $486.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.96 / $1,615.58 / $2,471.04
| Professional | | $1,124.96 | $1,615.58 | $2,471.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.87 / $1,249.95 / $2,112.89
| Professional | | $1,011.87 | $1,249.95 | $2,112.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.67 / $1,005.72 / $1,095.17
| Professional | | $967.67 | $1,005.72 | $1,095.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.22 / $1,327.27 / $1,852.31
| Professional | | $748.22 | $1,327.27 | $1,852.31 |