- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.75 / $1,060.75 / $1,413.18
| Facility | | $1,060.75 | $1,060.75 | $1,413.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.75 / $1,099.32 / $1,677.91
| Professional | | $1,060.75 | $1,099.32 | $1,677.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,026.26 / $2,127.57 / $9,353.21
| Facility | | $2,026.26 | $2,127.57 | $9,353.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.04 / $1,136.98 / $1,639.34
| Professional | | $1,027.04 | $1,136.98 | $1,639.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,277.46 / $1,277.46
| Facility | | $1,277.46 | $1,277.46 | $1,277.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.55 / $932.55 / $1,498.02
| Professional | | $932.55 | $932.55 | $1,498.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,049.20 / $1,640.08 / $10,083.62
| Facility | | $1,049.20 | $1,640.08 | $10,083.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.84 / $1,010.88 / $2,462.91
| Professional | | $777.84 | $1,010.88 | $2,462.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.11 / $1,010.88 / $1,630.17
| Professional | | $735.11 | $1,010.88 | $1,630.17 |