- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.54 / $1,093.74 / $1,373.10
| Facility | | $1,091.54 | $1,093.74 | $1,373.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.34 / $1,093.74 / $1,619.23
| Professional | | $933.34 | $1,093.74 | $1,619.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,111.91 / $2,260.80 / $4,223.82
| Facility | | $2,111.91 | $2,260.80 | $4,223.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.51 / $1,300.05 / $1,748.84
| Professional | | $1,233.51 | $1,300.05 | $1,748.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $1,207.83
| Facility | | $1,207.83 | $1,207.83 | $1,207.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $1,207.83 / $1,308.25
| Professional | | $881.72 | $1,207.83 | $1,308.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.55 / $1,055.55 / $1,055.55
| Facility | | $1,055.55 | $1,055.55 | $1,055.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.96 / $1,085.34 / $1,583.93
| Professional | | $824.96 | $1,085.34 | $1,583.93 |