- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $4,897.79
| Facility | | $2,884.03 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,137.96
| Professional | | $1,000.00 | $1,202.26 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,778.28
| Facility | | $1,096.48 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,778.28 / $2,630.27
| Professional | | $1,096.48 | $1,778.28 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,412.54 / $2,884.03
| Professional | | $912.01 | $1,412.54 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,090.30 / $4,897.79
| Facility | | $1,513.56 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $1,778.28
| Professional | | $1,071.52 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,318.26 / $2,137.96
| Professional | | $851.14 | $1,318.26 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,248.07 / $8,709.64
| Facility | | $1,513.56 | $5,248.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $1,819.70
| Professional | | $1,096.48 | $1,380.38 | $1,819.70 |