- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,289.45 / $1,289.45 / $1,289.45
| Facility | | $1,289.45 | $1,289.45 | $1,289.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.48 / $1,289.45 / $3,729.74
| Professional | | $1,066.48 | $1,289.45 | $3,729.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,854.26 / $2,860.24 / $3,568.28
| Professional | | $2,854.26 | $2,860.24 | $3,568.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,525.07 / $2,000.00 / $3,384.36
| Facility | | $1,525.07 | $2,000.00 | $3,384.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.55 / $2,518.41 / $11,552.00
| Professional | | $1,492.55 | $2,518.41 | $11,552.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,942.35 / $3,170.21 / $4,048.27
| Facility | | $1,942.35 | $3,170.21 | $4,048.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.00 / $2,878.43 / $3,509.29
| Professional | | $2,110.00 | $2,878.43 | $3,509.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.70 / $2,174.85 / $2,558.48
| Professional | | $1,613.70 | $2,174.85 | $2,558.48 |
- 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
- $1,649.90 / $2,268.46 / $3,528.73
| Professional | | $1,649.90 | $2,268.46 | $3,528.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.40 / $2,933.40 / $3,050.80
| Professional | | $2,493.40 | $2,933.40 | $3,050.80 |