- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $10,471.29
| Facility | | $1,096.48 | $1,096.48 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,737.80
| Professional | | $1,000.00 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $2,884.03
| Professional | | $2,041.74 | $2,454.71 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,089.30 / $3,467.37
| Professional | | $1,148.15 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $3,235.94
| Facility | | $1,096.48 | $1,412.54 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,949.84 / $2,818.38
| Professional | | $1,148.15 | $1,949.84 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,022.64 / $14,125.38
| Facility | | $10,715.19 | $12,022.64 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,949.84 / $2,630.27
| Professional | | $1,148.15 | $1,949.84 | $2,630.27 |