- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $3,090.30
| Professional | | $1,047.13 | $1,230.27 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,380.38 / $1,698.24
| Professional | | $1,230.27 | $1,380.38 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $645.65
| Facility | | $512.86 | $512.86 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,691.53
| Professional | | $1,122.02 | $1,513.56 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $2,089.30
| Professional | | $1,122.02 | $1,258.93 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $2,884.03
| Facility | | $776.25 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,398.83
| Professional | | $1,000.00 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,348.96 / $1,698.24
| Professional | | $1,174.90 | $1,348.96 | $1,698.24 |