- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,202.26
| Facility | | $1,174.90 | $1,174.90 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $1,479.11
| Professional | | $1,000.00 | $1,174.90 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $1,412.54
| Professional | | $954.99 | $1,258.93 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,238.72 / $3,630.78
| Professional | | $1,071.52 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $2,238.72
| Facility | | $1,174.90 | $1,698.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $7,244.36
| Professional | | $1,288.25 | $2,187.76 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,995.26 / $2,754.23
| Professional | | $1,202.26 | $1,995.26 | $2,754.23 |