- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,410.48 / $1,410.48 / $1,410.48
| Facility | | $1,410.48 | $1,410.48 | $1,410.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.48 / $1,410.48 / $1,451.72
| Professional | | $1,410.48 | $1,410.48 | $1,451.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.00 / $1,736.25 / $1,736.25
| Professional | | $1,389.00 | $1,736.25 | $1,736.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,268.66 / $2,453.41
| Facility | | $2,000.00 | $2,268.66 | $2,453.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.59 / $3,595.40 / $10,755.60
| Professional | | $2,123.59 | $3,595.40 | $10,755.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,746.15 / $3,212.31 / $4,581.92
| Facility | | $1,746.15 | $3,212.31 | $4,581.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,742.85 / $4,166.59 / $4,581.92
| Professional | | $2,742.85 | $4,166.59 | $4,581.92 |
- 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
- $1,977.47 / $3,096.40 / $5,056.16
| Professional | | $1,977.47 | $3,096.40 | $5,056.16 |