- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,071.52 / $3,090.30
| Facility | | $1,047.13 | $1,071.52 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,071.52 / $1,096.48
| Professional | | $1,047.13 | $1,071.52 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $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
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,412.54
| Professional | | $1,202.26 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $2,187.76 / $2,398.83
| Professional | | $50.12 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,288.25
| Facility | | $812.83 | $812.83 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,258.93
| Professional | | $1,230.27 | $1,230.27 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,258.93
| Professional | | $1,202.26 | $1,258.93 | $1,258.93 |