- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,584.89 / $8,511.38
| Facility | | $1,513.56 | $1,584.89 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,584.89 / $2,570.40
| Professional | | $1,000.00 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $3,890.45
| Professional | | $2,691.53 | $3,235.94 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $4,365.16
| Professional | | $2,089.30 | $2,630.27 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $4,466.84
| Facility | | $1,513.56 | $2,089.30 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,754.23 / $3,467.37
| Professional | | $1,548.82 | $2,754.23 | $3,467.37 |
- 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
- $1,548.82 / $2,818.38 / $3,715.35
| Professional | | $1,548.82 | $2,818.38 | $3,715.35 |