- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.65 / $1,166.65 / $1,166.65
| Facility | | $1,166.65 | $1,166.65 | $1,166.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.50 / $1,166.65 / $1,166.65
| Professional | | $1,080.50 | $1,166.65 | $1,166.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,267.52 / $2,404.30 / $3,005.38
| Professional | | $2,267.52 | $2,404.30 | $3,005.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,431.53 / $1,971.64 / $2,992.26
| Facility | | $1,431.53 | $1,971.64 | $2,992.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.25 / $2,225.31 / $11,932.00
| Professional | | $1,208.25 | $2,225.31 | $11,932.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.00 / $2,715.71 / $3,532.06
| Facility | | $2,095.00 | $2,715.71 | $3,532.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.23 / $2,482.52 / $3,070.93
| Professional | | $2,010.23 | $2,482.52 | $3,070.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.62 / $1,875.71 / $2,206.58
| Professional | | $1,360.62 | $1,875.71 | $2,206.58 |
- 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
- $1,208.25 / $2,306.66 / $3,072.33
| Professional | | $1,208.25 | $2,306.66 | $3,072.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.00 / $2,677.60 / $2,784.70
| Professional | | $2,276.00 | $2,677.60 | $2,784.70 |