- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.30 / $1,125.30 / $1,125.30
| Facility | | $1,125.30 | $1,125.30 | $1,125.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.97 / $1,125.30 / $1,137.50
| Professional | | $930.97 | $1,125.30 | $1,137.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.12 / $2,482.98 / $3,103.74
| Professional | | $1,805.12 | $2,482.98 | $3,103.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.22 / $1,649.58 / $3,034.10
| Facility | | $1,106.22 | $1,649.58 | $3,034.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.17 / $2,208.00 / $9,902.00
| Professional | | $1,281.17 | $2,208.00 | $9,902.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,724.21 / $2,596.44 / $3,622.81
| Facility | | $1,724.21 | $2,596.44 | $3,622.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.00 / $2,555.30 / $3,120.18
| Professional | | $1,531.00 | $2,555.30 | $3,120.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.83 / $1,957.59 / $2,271.27
| Professional | | $1,299.83 | $1,957.59 | $2,271.27 |
- 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
- $1,281.17 / $2,011.48 / $3,128.97
| Professional | | $1,281.17 | $2,011.48 | $3,128.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.50 / $2,708.30 / $2,708.30
| Professional | | $2,213.50 | $2,708.30 | $2,708.30 |