- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $2,041.74
| Facility | | $794.33 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,905.46
| Professional | | $812.83 | $1,096.48 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $4,466.84
| Facility | | $831.76 | $1,122.02 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $2,511.89
| Professional | | $1,096.48 | $1,230.27 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,584.89 / $9,120.11
| Facility | | $1,513.56 | $1,584.89 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $3,548.13
| Professional | | $1,148.15 | $1,148.15 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $2,454.71
| Facility | | $1,202.26 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,584.89
| Professional | | $758.58 | $1,047.13 | $1,584.89 |