- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,337.79 / $2,307.55
| Facility | | $1,045.15 | $1,337.79 | $2,307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,055.59 / $1,285.97
| Professional | | $1,045.15 | $1,055.59 | $1,285.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.36 / $1,739.13 / $3,323.05
| Facility | | $1,058.36 | $1,739.13 | $3,323.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.99 / $1,045.15 / $1,045.15
| Facility | | $985.99 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.55 / $1,273.13 / $1,721.86
| Facility | | $1,043.55 | $1,273.13 | $1,721.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,306.96
| Professional | | $1,045.15 | $1,045.15 | $1,306.96 |