- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.77 / $1,043.68 / $1,195.73
| Facility | | $941.77 | $1,043.68 | $1,195.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.55 / $1,043.68 / $1,990.34
| Professional | | $819.55 | $1,043.68 | $1,990.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.41 / $1,179.41 / $1,179.41
| Facility | | $1,179.41 | $1,179.41 | $1,179.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.97 / $860.97 / $1,194.75
| Professional | | $860.97 | $860.97 | $1,194.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $787.36 / $1,395.87 / $1,395.87
| Facility | | $787.36 | $1,395.87 | $1,395.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.38 / $1,406.00 / $2,273.02
| Professional | | $1,083.38 | $1,406.00 | $2,273.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.35 / $1,092.84 / $1,202.13
| Professional | | $710.35 | $1,092.84 | $1,202.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.00 / $1,110.32 / $1,350.91
| Professional | | $855.00 | $1,110.32 | $1,350.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.84 / $1,092.84 / $1,130.79
| Professional | | $1,092.84 | $1,092.84 | $1,130.79 |