- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,096.48 / $8,511.38
| Facility | | $1,071.52 | $1,096.48 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $2,570.40
| Professional | | $1,000.00 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $2,818.38
| Professional | | $1,905.46 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,041.74 / $3,388.44
| Professional | | $1,202.26 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $2,344.23
| Facility | | $1,071.52 | $1,479.11 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,041.74 / $10,232.93
| Professional | | $1,122.02 | $2,041.74 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $11,481.54
| Facility | | $1,819.70 | $2,041.74 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,041.74 / $2,570.40
| Professional | | $1,148.15 | $2,041.74 | $2,570.40 |