- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,468.21 / $1,468.21 / $1,468.21
| Facility | | $1,468.21 | $1,468.21 | $1,468.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.11 / $1,468.21 / $1,468.21
| Professional | | $1,436.11 | $1,468.21 | $1,468.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,361.54 / $2,481.27
| Facility | | $2,000.00 | $2,361.54 | $2,481.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.02 / $3,657.86 / $11,196.56
| Professional | | $2,157.02 | $3,657.86 | $11,196.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,727.38 / $1,921.66 / $2,696.87
| Facility | | $1,727.38 | $1,921.66 | $2,696.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.66 / $2,696.87 / $7,615.52
| Professional | | $1,921.66 | $2,696.87 | $7,615.52 |
- 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
- $2,011.82 / $3,301.07 / $5,135.00
| Professional | | $2,011.82 | $3,301.07 | $5,135.00 |