- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.32 / $1,106.32 / $1,106.32
| Facility | | $1,106.32 | $1,106.32 | $1,106.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.14 / $1,106.32 / $3,738.89
| Professional | | $863.14 | $1,106.32 | $3,738.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.36 / $2,557.79 / $3,197.23
| Professional | | $2,324.36 | $2,557.79 | $3,197.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.33 / $1,600.87 / $2,595.48
| Facility | | $1,220.33 | $1,600.87 | $2,595.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.64 / $2,286.73 / $8,833.41
| Professional | | $1,332.64 | $2,286.73 | $8,833.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,601.00 / $2,670.71 / $3,718.76
| Facility | | $1,601.00 | $2,670.71 | $3,718.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.00 / $2,323.04 / $3,260.69
| Professional | | $1,320.00 | $2,323.04 | $3,260.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.53 / $1,994.10 / $2,390.30
| Professional | | $1,389.53 | $1,994.10 | $2,390.30 |
- 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
- $1,221.58 / $2,397.21 / $3,095.06
| Professional | | $1,221.58 | $2,397.21 | $3,095.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.30 / $2,789.70 / $2,901.30
| Professional | | $2,371.30 | $2,789.70 | $2,901.30 |