- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,412.54
| Facility | | $1,047.13 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,122.02 / $1,258.93
| Professional | | $1,047.13 | $1,122.02 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,348.96
| Facility | | $1,071.52 | $1,071.52 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $1,737.80 / $1,737.80
| Facility | | $34.67 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,584.89 / $7,079.46
| Professional | | $851.14 | $1,584.89 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $10,232.93
| Facility | | $8,511.38 | $8,511.38 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,174.90 / $1,778.28
| Professional | | $851.14 | $1,174.90 | $1,778.28 |