- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,419.88 / $1,419.88 / $3,645.64
| Facility | | $1,419.88 | $1,419.88 | $3,645.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.88 / $1,843.07 / $3,645.64
| Professional | | $1,419.88 | $1,843.07 | $3,645.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,382.56 / $4,382.56 / $4,382.56
| Facility | | $4,382.56 | $4,382.56 | $4,382.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.14 / $2,055.03 / $4,382.56
| Professional | | $1,974.14 | $2,055.03 | $4,382.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,400.00 / $3,001.55
| Facility | | $2,400.00 | $2,400.00 | $3,001.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.00 / $2,400.00 / $2,896.43
| Professional | | $1,752.00 | $2,400.00 | $2,896.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,437.09 / $3,506.05 / $5,697.33
| Professional | | $2,437.09 | $3,506.05 | $5,697.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.95 / $1,639.81 / $2,733.01
| Professional | | $1,283.95 | $1,639.81 | $2,733.01 |