- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,369.76 / $1,369.76 / $1,369.76
| Facility | | $1,369.76 | $1,369.76 | $1,369.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.06 / $1,369.76 / $1,369.76
| Professional | | $1,264.06 | $1,369.76 | $1,369.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.33 / $2,810.21 / $3,512.77
| Professional | | $2,650.33 | $2,810.21 | $3,512.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.64 / $2,136.26 / $4,239.43
| Facility | | $1,318.64 | $2,136.26 | $4,239.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.45 / $3,084.08 / $9,631.68
| Professional | | $1,850.45 | $3,084.08 | $9,631.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,913.37 / $3,195.61 / $4,179.68
| Facility | | $2,913.37 | $3,195.61 | $4,179.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,421.82 / $3,194.64 / $3,974.16
| Professional | | $2,421.82 | $3,194.64 | $3,974.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.47 / $2,460.23 / $2,776.07
| Professional | | $1,878.47 | $2,460.23 | $2,776.07 |
- 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
- $1,725.76 / $2,634.20 / $3,641.79
| Professional | | $1,725.76 | $2,634.20 | $3,641.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,671.00 / $3,142.40 / $3,268.00
| Professional | | $2,671.00 | $3,142.40 | $3,268.00 |