- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.35 / $1,029.35 / $1,029.35
| Facility | | $1,029.35 | $1,029.35 | $1,029.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.54 / $1,029.35 / $1,082.97
| Professional | | $927.54 | $1,029.35 | $1,082.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.29 / $2,455.71 / $3,069.65
| Professional | | $1,785.29 | $2,455.71 | $3,069.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.38 / $1,855.08 / $2,911.91
| Facility | | $1,078.38 | $1,855.08 | $2,911.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.33 / $2,088.42 / $9,419.54
| Professional | | $1,286.33 | $2,088.42 | $9,419.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.32 / $2,504.46 / $3,375.64
| Facility | | $1,671.32 | $2,504.46 | $3,375.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.00 / $2,404.64 / $2,910.62
| Professional | | $1,728.00 | $2,404.64 | $2,910.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.22 / $1,835.17 / $2,137.36
| Professional | | $1,338.22 | $1,835.17 | $2,137.36 |
- 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
- $1,286.33 / $2,143.90 / $3,003.14
| Professional | | $1,286.33 | $2,143.90 | $3,003.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.30 / $2,594.30 / $2,594.30
| Professional | | $2,120.30 | $2,594.30 | $2,594.30 |