- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,548.82 / $2,089.30
| Facility | | $1,445.44 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,548.82 / $2,238.72
| Professional | | $1,174.90 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,949.84 / $1,949.84
| Professional | | $1,000.00 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,981.07 / $5,495.41
| Facility | | $1,258.93 | $3,981.07 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $14,454.40 / $14,454.40
| Professional | | $9,772.37 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,949.84 / $1,949.84
| Facility | | $691.83 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,949.84
| Professional | | $812.83 | $1,174.90 | $1,949.84 |