- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.65 / $1,157.65 / $1,157.65
| Facility | | $1,157.65 | $1,157.65 | $1,157.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.97 / $1,157.65 / $1,253.76
| Professional | | $1,135.97 | $1,157.65 | $1,253.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.13 / $1,297.44 / $1,595.16
| Professional | | $1,276.13 | $1,297.44 | $1,595.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.76 / $1,956.43 / $2,507.52
| Facility | | $1,172.76 | $1,956.43 | $2,507.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.51 / $2,032.74 / $7,680.91
| Professional | | $1,358.51 | $2,032.74 | $7,680.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.45 / $2,105.19 / $2,759.12
| Facility | | $1,650.45 | $2,105.19 | $2,759.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.00 / $1,829.35 / $2,369.39
| Professional | | $1,294.00 | $1,829.35 | $2,369.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.88 / $2,070.73 / $2,411.00
| Professional | | $1,444.88 | $2,070.73 | $2,411.00 |
- 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
- $1,358.51 / $2,457.56 / $3,162.04
| Professional | | $1,358.51 | $2,457.56 | $3,162.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.50 / $2,115.19 / $2,115.19
| Professional | | $1,745.50 | $2,115.19 | $2,115.19 |