- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,584.89
| Facility | | $1,023.29 | $1,023.29 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,905.46
| Professional | | $794.33 | $1,047.13 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,479.11
| Professional | | $1,071.52 | $1,071.52 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $2,344.23
| Facility | | $1,122.02 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $870.96 / $1,318.26
| Professional | | $575.44 | $870.96 | $1,318.26 |