- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,691.53
| Facility | | $1,096.48 | $1,412.54 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,398.83
| Professional | | $1,096.48 | $1,412.54 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $5,888.44
| Facility | | $1,096.48 | $1,479.11 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $3,162.28
| Professional | | $1,412.54 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $11,481.54
| Facility | | $1,479.11 | $1,479.11 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $4,365.16
| Professional | | $1,096.48 | $1,096.48 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $3,235.94
| Facility | | $1,412.54 | $1,778.28 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $2,041.74
| Professional | | $1,000.00 | $1,318.26 | $2,041.74 |