- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,256.40 / $1,256.40 / $1,256.40
| Facility | | $1,256.40 | $1,256.40 | $1,256.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.19 / $1,256.40 / $1,256.40
| Professional | | $1,229.19 | $1,256.40 | $1,256.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.34 / $2,138.34 / $2,742.04
| Professional | | $2,138.34 | $2,138.34 | $2,742.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.74 / $2,020.83 / $2,123.32
| Facility | | $1,757.74 | $2,020.83 | $2,123.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,112.05 / $3,582.82 / $9,583.28
| Professional | | $2,112.05 | $3,582.82 | $9,583.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,681.54 / $2,351.50 / $3,212.31
| Facility | | $1,681.54 | $2,351.50 | $3,212.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.34 / $2,351.50 / $3,212.31
| Professional | | $2,138.34 | $2,351.50 | $3,212.31 |
- 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
- $1,432.49 / $3,233.43 / $5,029.78
| Professional | | $1,432.49 | $3,233.43 | $5,029.78 |