- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.14 / $1,169.44 / $2,088.28
| Facility | | $1,044.14 | $1,169.44 | $2,088.28 |
- 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
- $1,245.71 / $1,881.27 / $4,741.22
| Facility | | $1,245.71 | $1,881.27 | $4,741.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.14 / $1,045.15 / $1,045.15
| Professional | | $1,044.14 | $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
- Professional
- Modifier
- Low / Median / High Price
- $1,096.57 / $1,697.32 / $3,225.86
| Professional | | $1,096.57 | $1,697.32 | $3,225.86 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,244.40 / $1,368.84 / $1,742.16
| Professional | | $1,244.40 | $1,368.84 | $1,742.16 |