- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.30 / $1,158.30 / $1,240.77
| Facility | | $1,158.30 | $1,158.30 | $1,240.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.30 / $1,158.30 / $1,158.30
| Professional | | $1,158.30 | $1,158.30 | $1,158.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.01 / $1,538.88 / $2,976.70
| Facility | | $1,170.01 | $1,538.88 | $2,976.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,815.80 / $3,038.09 / $3,198.00
| Professional | | $2,815.80 | $3,038.09 | $3,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.00 / $3,541.44 / $4,426.80
| Professional | | $2,340.00 | $3,541.44 | $4,426.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.30 / $2,200.77 / $9,262.50
| Facility | | $1,158.30 | $2,200.77 | $9,262.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.00 / $1,053.00 / $5,635.50
| Professional | | $1,053.00 | $1,053.00 | $5,635.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,340.00 / $3,837.02 / $5,422.95
| Facility | | $2,340.00 | $3,837.02 | $5,422.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.00 / $3,837.02 / $4,972.50
| Professional | | $2,340.00 | $3,837.02 | $4,972.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.50 / $2,281.50 / $3,978.00
| Professional | | $2,281.50 | $2,281.50 | $3,978.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.00 / $1,930.50 / $7,800.00
| Facility | | $1,053.00 | $1,930.50 | $7,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.35 / $1,053.00 / $3,510.00
| Professional | | $1,000.35 | $1,053.00 | $3,510.00 |