- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.61 / $1,154.61 / $1,154.61
| Facility | | $1,154.61 | $1,154.61 | $1,154.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.16 / $1,229.55 / $1,727.58
| Professional | | $906.16 | $1,229.55 | $1,727.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.90 / $1,650.90 / $2,029.15
| Facility | | $1,650.90 | $1,650.90 | $2,029.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.27 / $1,403.27 / $1,776.79
| Professional | | $1,403.27 | $1,403.27 | $1,776.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.82 / $2,232.07 / $2,870.39
| Professional | | $1,866.82 | $2,232.07 | $2,870.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.76 / $1,349.76 / $1,349.76
| Professional | | $1,349.76 | $1,349.76 | $1,349.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,224.69 / $2,161.65 / $2,162.13
| Facility | | $1,224.69 | $2,161.65 | $2,162.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.74 / $1,217.49 / $2,029.15
| Professional | | $980.74 | $1,217.49 | $2,029.15 |