- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,199.51 / $1,199.51 / $2,236.58
| Facility | | $1,199.51 | $1,199.51 | $2,236.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.30 / $1,060.42 / $2,236.58
| Professional | | $920.30 | $1,060.42 | $2,236.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.53 / $1,655.53 / $1,655.53
| Professional | | $1,655.53 | $1,655.53 | $1,655.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.06 / $2,262.15 / $2,981.30
| Facility | | $1,012.06 | $2,262.15 | $2,981.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.10 / $1,557.43 / $3,248.67
| Professional | | $978.10 | $1,557.43 | $3,248.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.47 / $1,296.83 / $2,808.85
| Facility | | $915.47 | $1,296.83 | $2,808.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.99 / $1,756.80 / $6,610.61
| Professional | | $731.99 | $1,756.80 | $6,610.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.13 / $1,681.20 / $2,547.36
| Professional | | $758.13 | $1,681.20 | $2,547.36 |