- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,445.44 / $8,511.38
| Facility | | $1,412.54 | $1,445.44 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $2,344.23
| Professional | | $1,000.00 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $3,715.35
| Professional | | $2,511.89 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $4,073.80
| Professional | | $1,949.84 | $2,398.83 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $4,265.80
| Facility | | $1,412.54 | $1,949.84 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,691.53 / $3,311.31
| Professional | | $1,548.82 | $2,691.53 | $3,311.31 |
- 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 / $2,691.53 / $3,548.13
| Professional | | $1,548.82 | $2,691.53 | $3,548.13 |