- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.63 / $1,137.63 / $1,137.63
| Facility | | $1,137.63 | $1,137.63 | $1,137.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.85 / $1,137.63 / $3,476.51
| Professional | | $1,024.85 | $1,137.63 | $3,476.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.07 / $2,688.67 / $3,360.84
| Professional | | $2,628.07 | $2,688.67 | $3,360.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.70 / $1,922.59 / $3,238.26
| Facility | | $1,463.70 | $1,922.59 | $3,238.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.65 / $2,401.08 / $9,503.76
| Professional | | $1,440.65 | $2,401.08 | $9,503.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,883.25 / $2,976.79 / $3,675.99
| Facility | | $1,883.25 | $2,976.79 | $3,675.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.00 / $2,628.07 / $3,188.63
| Professional | | $2,007.00 | $2,628.07 | $3,188.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.78 / $2,013.87 / $2,335.96
| Professional | | $1,512.78 | $2,013.87 | $2,335.96 |
- 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
- $1,440.65 / $2,389.38 / $3,364.20
| Professional | | $1,440.65 | $2,389.38 | $3,364.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,317.40 / $2,726.30 / $2,835.40
| Professional | | $2,317.40 | $2,726.30 | $2,835.40 |