- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,122.02 / $8,511.38
| Facility | | $1,047.13 | $1,122.02 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $2,290.87
| Professional | | $1,047.13 | $1,202.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,019.95
| Professional | | $2,137.96 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,137.96 / $3,162.28
| Professional | | $1,174.90 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,398.83
| Facility | | $1,122.02 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,778.28 / $8,511.38
| Professional | | $1,000.00 | $1,778.28 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $2,454.71
| Professional | | $1,000.00 | $1,548.82 | $2,454.71 |