- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,801.89 / $7,244.36
| Facility | | $1,071.52 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,548.82
| Professional | | $1,071.52 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,621.81 / $2,137.96
| Professional | | $1,548.82 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,890.45 / $8,709.64
| Facility | | $1,000.00 | $3,890.45 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,318.26 / $2,630.27
| Facility | | $1,148.15 | $1,318.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $1,862.09
| Facility | | $1,380.38 | $1,548.82 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $1,548.82
| Professional | | $645.65 | $912.01 | $1,548.82 |