- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $4,897.79
| Facility | | $1,380.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $1,862.09
| Professional | | $1,000.00 | $1,174.90 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $1,000.00 / $1,000.00
| Facility | | $323.59 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,621.81 / $1,659.59
| Professional | | $323.59 | $1,621.81 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $1,778.28
| Professional | | $977.24 | $1,148.15 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,162.28 / $4,897.79
| Facility | | $1,380.38 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,621.81
| Professional | | $1,047.13 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,174.90 / $1,698.24
| Professional | | $1,071.52 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,025.60
| Facility | | $1,698.24 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $1,778.28
| Professional | | $1,071.52 | $1,348.96 | $1,778.28 |