- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,071.52 / $1,202.26
| Facility | | $977.24 | $1,071.52 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $1,819.70
| Professional | | $977.24 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,949.84
| Professional | | $1,445.44 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,148.15
| Facility | | $794.33 | $794.33 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,412.54 / $2,344.23
| Professional | | $524.81 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,071.52 / $1,348.96
| Professional | | $707.95 | $1,071.52 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $2,290.87
| Facility | | $1,047.13 | $1,737.80 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $1,737.80
| Professional | | $1,000.00 | $1,148.15 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $2,344.23
| Professional | | $1,071.52 | $1,071.52 | $2,344.23 |