- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $955.64 / $955.64 / $1,044.11
| Facility | | $955.64 | $955.64 | $1,044.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.94 / $1,002.62 / $1,788.68
| Professional | | $937.94 | $1,002.62 | $1,788.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.57 / $1,911.71 / $1,911.71
| Professional | | $1,265.57 | $1,911.71 | $1,911.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,135.42 / $1,327.28 / $1,327.28
| Facility | | $1,135.42 | $1,327.28 | $1,327.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.91 / $968.91 / $1,327.28
| Professional | | $968.91 | $968.91 | $1,327.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,547.62 / $11,068.57 / $12,032.65
| Facility | | $3,547.62 | $11,068.57 | $12,032.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,159.31 / $12,159.31 / $17,099.78
| Professional | | $12,159.31 | $12,159.31 | $17,099.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.47 / $1,037.58 / $1,520.27
| Professional | | $706.47 | $1,037.58 | $1,520.27 |