- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.08 / $1,120.08 / $1,120.08
| Facility | | $1,120.08 | $1,120.08 | $1,120.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.08 / $1,120.08 / $1,151.78
| Professional | | $1,120.08 | $1,120.08 | $1,151.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.93 / $1,567.93 / $1,832.34
| Professional | | $1,567.93 | $1,567.93 | $1,832.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,647.05 / $1,892.95 / $2,000.00
| Facility | | $1,647.05 | $1,892.95 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.62 / $2,372.60 / $8,541.52
| Professional | | $1,396.62 | $2,372.60 | $8,541.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.02 / $1,724.22 / $1,996.56
| Facility | | $1,385.02 | $1,724.22 | $1,996.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.93 / $1,745.11 / $2,115.13
| Professional | | $1,567.93 | $1,745.11 | $2,115.13 |
- 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
- $1,193.26 / $2,141.37 / $3,331.02
| Professional | | $1,193.26 | $2,141.37 | $3,331.02 |