- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.20 / $2,548.92 / $3,103.16
| Facility | | $1,481.20 | $2,548.92 | $3,103.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.25 / $938.96 / $1,016.32
| Professional | | $808.25 | $938.96 | $1,016.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.63 / $2,326.06 / $2,919.31
| Facility | | $1,277.63 | $2,326.06 | $2,919.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.25 / $800.25 / $1,088.33
| Professional | | $800.25 | $800.25 | $1,088.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.50 / $1,067.80 / $1,536.94
| Facility | | $785.50 | $1,067.80 | $1,536.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.25 / $889.25 / $1,600.65
| Professional | | $889.25 | $889.25 | $1,600.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.25 / $889.25 / $1,612.03
| Professional | | $889.25 | $889.25 | $1,612.03 |