- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $4,897.79
| Facility | | $1,778.28 | $1,778.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,137.96
| Professional | | $1,479.11 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,079.46
| Facility | | $4,897.79 | $4,897.79 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $2,238.72
| Professional | | $1,445.44 | $1,995.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,548.13 / $5,888.44
| Facility | | $1,698.24 | $3,548.13 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,691.53 / $3,388.44
| Professional | | $2,570.40 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,238.72
| Facility | | $1,318.26 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,659.59
| Professional | | $1,445.44 | $1,445.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,238.72 / $2,691.53
| Facility | | $1,122.02 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $2,238.72
| Professional | | $1,000.00 | $1,122.02 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |