- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.74 / $1,233.74 / $2,290.00
| Facility | | $1,233.74 | $1,233.74 | $2,290.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.96 / $1,004.33 / $1,233.74
| Professional | | $224.96 | $1,004.33 | $1,233.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.62 / $1,697.32 / $2,394.80
| Facility | | $378.62 | $1,697.32 | $2,394.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.66 / $2,400.98 / $8,918.24
| Professional | | $1,257.66 | $2,400.98 | $8,918.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,510.74 / $1,661.34 / $2,329.63
| Facility | | $1,510.74 | $1,661.34 | $2,329.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.74 / $1,661.34 / $1,923.74
| Professional | | $1,510.74 | $1,661.34 | $1,923.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.66 / $2,142.38 / $3,210.37
| Professional | | $1,257.66 | $2,142.38 | $3,210.37 |