- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.43 / $1,232.43 / $1,478.92
| Facility | | $1,232.43 | $1,232.43 | $1,478.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.34 / $956.34 / $1,232.43
| Professional | | $780.34 | $956.34 | $1,232.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,188.77 / $2,188.77 / $2,594.57
| Facility | | $2,188.77 | $2,188.77 | $2,594.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.60 / $1,062.60 / $1,115.08
| Professional | | $1,062.60 | $1,062.60 | $1,115.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,375.24 / $1,375.24
| Facility | | $1,375.24 | $1,375.24 | $1,375.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.93 / $1,003.93 / $1,416.50
| Professional | | $1,003.93 | $1,003.93 | $1,416.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.14 / $1,772.14 / $5,469.71
| Professional | | $1,772.14 | $1,772.14 | $5,469.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.97 / $1,091.95 / $1,343.35
| Professional | | $727.97 | $1,091.95 | $1,343.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.32 / $1,803.25 / $2,295.05
| Professional | | $1,639.32 | $1,803.25 | $2,295.05 |