- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $4,570.88
| Facility | | $1,148.15 | $1,548.82 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,174.90 / $1,949.84
| Professional | | $1,023.29 | $1,174.90 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $4,073.80
| Facility | | $1,000.00 | $1,000.00 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,238.72
| Professional | | $1,862.09 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $2,691.53
| Facility | | $1,148.15 | $1,548.82 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $5,754.40
| Professional | | $645.65 | $645.65 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,548.82 / $1,862.09
| Facility | | $645.65 | $1,548.82 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $1,023.29
| Professional | | $645.65 | $645.65 | $1,023.29 |