- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,524.87 / $1,524.87 / $1,524.87
| Facility | | $1,524.87 | $1,524.87 | $1,524.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.87 / $1,452.25 / $1,524.87
| Professional | | $238.87 | $1,452.25 | $1,524.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,815.32 / $3,461.83
| Professional | | $1,452.25 | $1,815.32 | $3,461.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,452.25 / $1,452.25
| Facility | | $1,370.05 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.97 / $1,677.36 / $3,000.00
| Facility | | $266.97 | $1,677.36 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.97 / $266.97 / $266.97
| Professional | | $266.97 | $266.97 | $266.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.44 / $1,644.99 / $1,811.29
| Professional | | $230.44 | $1,644.99 | $1,811.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.03 / $1,452.25 / $1,597.48
| Professional | | $1,307.03 | $1,452.25 | $1,597.48 |