- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.78 / $1,285.78 / $1,285.78
| Facility | | $1,285.78 | $1,285.78 | $1,285.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.78 / $1,285.78 / $1,348.33
| Professional | | $1,285.78 | $1,285.78 | $1,348.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.63 / $1,889.53 / $1,889.53
| Professional | | $1,511.63 | $1,889.53 | $1,889.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,928.11 / $2,068.05 / $2,278.67
| Facility | | $1,928.11 | $2,068.05 | $2,278.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.11 / $2,788.34 / $10,512.16
| Professional | | $1,646.11 | $2,788.34 | $10,512.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.88 / $2,496.55 / $3,458.97
| Facility | | $1,621.88 | $2,496.55 | $3,458.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,291.21 / $3,145.42 / $3,458.97
| Professional | | $2,291.21 | $3,145.42 | $3,458.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.11 / $2,788.34 / $3,632.92
| Professional | | $1,646.11 | $2,788.34 | $3,632.92 |