- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $3,548.13
| Facility | | $1,071.52 | $1,071.52 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,071.52 / $1,584.89
| Professional | | $1,000.00 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,380.38
| Facility | | $1,148.15 | $1,148.15 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $4,168.69
| Facility | | $1,862.09 | $1,862.09 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $6,025.60
| Professional | | $912.01 | $1,548.82 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $16,595.87
| Facility | | $3,548.13 | $3,548.13 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $1,819.70
| Professional | | $851.14 | $1,148.15 | $1,819.70 |