- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.02 / $1,311.02 / $1,502.04
| Facility | | $1,219.02 | $1,311.02 | $1,502.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.82 / $1,502.04 / $2,125.16
| Professional | | $1,222.82 | $1,502.04 | $2,125.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $1,784.15 / $1,784.15
| Facility | | $1,784.15 | $1,784.15 | $1,784.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,302.43 / $1,837.67
| Professional | | $1,302.43 | $1,302.43 | $1,837.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.96 / $99,999.99 / $99,999.99
| Facility | | $988.96 | $99,999.99 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.46 / $2,006.56 / $2,855.29
| Professional | | $1,287.46 | $2,006.56 | $2,855.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.18 / $1,321.83 / $1,454.01
| Professional | | $859.18 | $1,321.83 | $1,454.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.15 / $1,424.47 / $2,146.23
| Professional | | $1,226.15 | $1,424.47 | $2,146.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.83 / $1,321.83 / $1,727.76
| Professional | | $1,321.83 | $1,321.83 | $1,727.76 |