- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $6,606.93
| Facility | | $1,949.84 | $2,754.23 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $2,238.72
| Professional | | $1,122.02 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $5,248.07
| Facility | | $2,137.96 | $2,630.27 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,737.80
| Professional | | $1,122.02 | $1,122.02 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $1,737.80
| Facility | | $1,000.00 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Professional | | $3,801.89 | $3,801.89 | $3,801.89 |