- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $8,511.38
| Facility | | $1,288.25 | $1,288.25 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,187.76
| Professional | | $1,000.00 | $1,288.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,388.44
| Professional | | $2,290.87 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $4,073.80
| Professional | | $1,698.24 | $2,344.23 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,089.30 / $3,890.45
| Facility | | $1,288.25 | $2,089.30 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,344.23 / $2,818.38
| Professional | | $1,318.26 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,344.23 / $3,235.94
| Professional | | $1,318.26 | $2,344.23 | $3,235.94 |