- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $2,290.87
| Facility | | $1,096.48 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,238.72
| Professional | | $1,047.13 | $1,348.96 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $5,011.87
| Facility | | $1,023.29 | $1,412.54 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,380.38 / $3,090.30
| Professional | | $1,348.96 | $1,380.38 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $10,232.93
| Facility | | $1,737.80 | $1,737.80 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,890.45
| Professional | | $1,288.25 | $1,288.25 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,698.24 / $3,090.30
| Facility | | $977.24 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $1,905.46
| Professional | | $933.25 | $1,318.26 | $1,905.46 |