- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.30 / $1,011.30 / $1,347.30
| Facility | | $1,011.30 | $1,011.30 | $1,347.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.91 / $1,048.07 / $1,599.69
| Professional | | $992.91 | $1,048.07 | $1,599.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.80 / $2,028.39 / $8,917.19
| Facility | | $1,931.80 | $2,028.39 | $8,917.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.32 / $1,148.64 / $1,563.64
| Professional | | $965.32 | $1,148.64 | $1,563.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.09 / $1,207.09 / $1,207.09
| Facility | | $1,207.09 | $1,207.09 | $1,207.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $881.18 / $1,243.31
| Professional | | $881.18 | $881.18 | $1,243.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.30 / $1,563.62 / $9,986.98
| Facility | | $1,011.30 | $1,563.62 | $9,986.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.47 / $963.76 / $2,348.10
| Professional | | $798.47 | $963.76 | $2,348.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.56 / $963.76 / $1,462.25
| Professional | | $742.56 | $963.76 | $1,462.25 |