- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,780.64 / $1,780.64 / $1,780.64
| Facility | | $1,780.64 | $1,780.64 | $1,780.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.76 / $1,780.64 / $1,975.86
| Professional | | $1,618.76 | $1,780.64 | $1,975.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,375.24 / $2,281.44
| Facility | | $1,375.24 | $1,375.24 | $2,281.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.50 / $2,464.50 / $3,080.63
| Professional | | $2,464.50 | $2,464.50 | $3,080.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,515.12 / $2,300.07 / $9,328.83
| Facility | | $1,515.12 | $2,300.07 | $9,328.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.05 / $1,345.86 / $2,370.88
| Professional | | $806.05 | $1,345.86 | $2,370.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,896.97 / $2,281.44 / $3,353.32
| Facility | | $1,896.97 | $2,281.44 | $3,353.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.50 / $2,313.54 / $4,359.78
| Professional | | $1,868.50 | $2,313.54 | $4,359.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.69 / $1,975.86 / $2,348.62
| Professional | | $1,687.69 | $1,975.86 | $2,348.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.58 / $1,162.33 / $1,682.33
| Professional | | $682.58 | $1,162.33 | $1,682.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.56 / $2,032.56 / $2,032.56
| Professional | | $2,032.56 | $2,032.56 | $2,032.56 |