- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,398.83
| Facility | | $1,258.93 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $2,290.87
| Professional | | $1,000.00 | $1,258.93 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,244.36 / $9,772.37
| Facility | | $6,165.95 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $2,041.74
| Professional | | $1,258.93 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,511.89
| Professional | | $933.25 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $7,244.36
| Facility | | $1,479.11 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,862.09
| Professional | | $851.14 | $1,122.02 | $1,862.09 |