- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $1,404.00 / $2,913.30
| Facility | | $1,404.00 | $1,404.00 | $2,913.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.08 / $1,404.00 / $1,491.75
| Professional | | $1,167.08 | $1,404.00 | $1,491.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,387.15 / $2,442.79 / $4,607.39
| Facility | | $1,387.15 | $2,442.79 | $4,607.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $1,755.00 / $2,871.53
| Facility | | $1,404.00 | $1,755.00 | $2,871.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.75 / $1,140.75 / $1,755.00
| Professional | | $1,140.75 | $1,140.75 | $1,755.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.00 / $2,983.50 / $3,734.25
| Professional | | $1,950.00 | $2,983.50 | $3,734.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.00 / $1,053.00 / $1,930.50
| Professional | | $819.00 | $1,053.00 | $1,930.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,393.00 / $9,262.50 / $9,262.50
| Facility | | $3,393.00 | $9,262.50 | $9,262.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,711.00 / $9,711.00 / $14,625.00
| Professional | | $9,711.00 | $9,711.00 | $14,625.00 |