- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $6,606.93
| Facility | | $1,288.25 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,862.09
| Professional | | $1,000.00 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $1,905.46
| Professional | | $1,202.26 | $1,737.80 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,737.80 / $6,309.57
| Facility | | $346.74 | $1,737.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $12,022.64
| Professional | | $1,000.00 | $1,380.38 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $1,949.84
| Professional | | $954.99 | $1,258.93 | $1,949.84 |