- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.31 / $1,450.31 / $1,740.37
| Facility | | $1,450.31 | $1,450.31 | $1,740.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.07 / $1,125.40 / $1,450.31
| Professional | | $863.07 | $1,125.40 | $1,450.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,575.73 / $2,575.73 / $3,053.28
| Facility | | $2,575.73 | $2,575.73 | $3,053.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.64 / $1,148.64 / $1,232.76
| Professional | | $1,148.64 | $1,148.64 | $1,232.76 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,085.46 / $2,085.46 / $6,436.80
| Professional | | $2,085.46 | $2,085.46 | $6,436.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.67 / $1,285.01 / $1,525.78
| Professional | | $856.67 | $1,285.01 | $1,525.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.14 / $2,122.05 / $2,700.80
| Professional | | $1,929.14 | $2,122.05 | $2,700.80 |