- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $5,128.61
| Facility | | $1,047.13 | $1,174.90 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,071.52 / $1,230.27
| Professional | | $1,047.13 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.04
| Facility | | $0.02 | $0.02 | $0.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $2,398.83
| Professional | | $933.25 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,096.48 / $1,096.48
| Facility | | $1,071.52 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,584.89
| Facility | | $812.83 | $812.83 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,412.54
| Professional | | $1,230.27 | $1,230.27 | $1,412.54 |