- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.55 / $1,240.55 / $1,240.55
| Facility | | $1,240.55 | $1,240.55 | $1,240.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.21 / $1,240.55 / $3,370.91
| Professional | | $1,013.21 | $1,240.55 | $3,370.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,627.35 / $2,681.66 / $3,352.08
| Professional | | $2,627.35 | $2,681.66 | $3,352.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.89 / $2,000.00 / $3,121.93
| Facility | | $1,448.89 | $2,000.00 | $3,121.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.81 / $2,285.40 / $9,848.32
| Professional | | $1,367.81 | $2,285.40 | $9,848.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,779.57 / $2,958.43 / $3,640.53
| Facility | | $1,779.57 | $2,958.43 | $3,640.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.00 / $2,627.35 / $3,221.05
| Professional | | $2,059.00 | $2,627.35 | $3,221.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,468.24 / $1,985.44 / $2,335.31
| Professional | | $1,468.24 | $1,985.44 | $2,335.31 |
- 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
- $1,367.81 / $2,279.67 / $3,284.62
| Professional | | $1,367.81 | $2,279.67 | $3,284.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.69 / $2,617.30 / $2,721.90
| Professional | | $2,224.69 | $2,617.30 | $2,721.90 |