- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.26 / $1,127.26 / $1,127.26
| Facility | | $1,127.26 | $1,127.26 | $1,127.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.31 / $1,127.26 / $1,127.26
| Professional | | $1,047.31 | $1,127.26 | $1,127.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.42 / $2,319.38 / $2,899.23
| Professional | | $2,187.42 | $2,319.38 | $2,899.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,397.58 / $1,905.07 / $3,054.06
| Facility | | $1,397.58 | $1,905.07 | $3,054.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.86 / $2,215.28 / $11,843.00
| Professional | | $1,235.86 | $2,215.28 | $11,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.00 / $2,662.77 / $3,487.22
| Facility | | $2,182.00 | $2,662.77 | $3,487.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.00 / $2,443.21 / $3,021.73
| Professional | | $1,997.00 | $2,443.21 | $3,021.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.47 / $1,904.76 / $2,171.64
| Professional | | $1,415.47 | $1,904.76 | $2,171.64 |
- 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
- $1,235.86 / $2,323.52 / $3,005.44
| Professional | | $1,235.86 | $2,323.52 | $3,005.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.00 / $2,635.20 / $2,740.70
| Professional | | $2,240.00 | $2,635.20 | $2,740.70 |