- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,104.81 / $1,107.07 / $1,389.81
| Facility | | $1,104.81 | $1,107.07 | $1,389.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.70 / $1,107.07 / $1,638.93
| Professional | | $944.70 | $1,107.07 | $1,638.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.66 / $2,288.32 / $4,275.32
| Facility | | $2,137.66 | $2,288.32 | $4,275.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.20 / $1,315.88 / $1,804.26
| Professional | | $1,216.20 | $1,315.88 | $1,804.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.54 / $1,222.54 / $1,222.54
| Facility | | $1,222.54 | $1,222.54 | $1,222.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.45 / $892.45 / $2,351.42
| Professional | | $892.45 | $892.45 | $2,351.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.37 / $2,608.67 / $2,608.67
| Facility | | $2,217.37 | $2,608.67 | $2,608.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.49 / $1,092.59 / $1,545.46
| Professional | | $817.49 | $1,092.59 | $1,545.46 |