- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.47 / $1,012.47 / $1,214.96
| Facility | | $1,012.47 | $1,012.47 | $1,214.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.02 / $785.65 / $1,012.47
| Professional | | $740.02 | $785.65 | $1,012.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,798.13 / $1,798.13 / $2,131.50
| Facility | | $1,798.13 | $1,798.13 | $2,131.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.36 / $1,002.36 / $1,050.24
| Professional | | $1,002.36 | $1,002.36 | $1,050.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.38 / $1,028.38 / $1,028.38
| Facility | | $1,028.38 | $1,028.38 | $1,028.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.72 / $750.72 / $1,028.38
| Professional | | $750.72 | $750.72 | $1,028.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.87 / $1,455.87 / $4,493.54
| Professional | | $1,455.87 | $1,455.87 | $4,493.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.04 / $897.07 / $1,065.16
| Professional | | $598.04 | $897.07 | $1,065.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.75 / $1,481.43 / $1,885.45
| Professional | | $1,346.75 | $1,481.43 | $1,885.45 |