- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,110.67 / $1,110.67 / $1,110.67
| Facility | | $1,110.67 | $1,110.67 | $1,110.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.47 / $1,110.67 / $1,355.33
| Professional | | $994.47 | $1,110.67 | $1,355.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,771.02 / $2,285.19 / $2,614.48
| Facility | | $1,771.02 | $2,285.19 | $2,614.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.34 / $1,711.10 / $1,711.10
| Professional | | $1,458.34 | $1,711.10 | $1,711.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Facility | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,314.00 / $1,800.00
| Professional | | $1,314.00 | $1,314.00 | $1,800.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.37 / $1,485.37 / $1,485.37
| Facility | | $1,485.37 | $1,485.37 | $1,485.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.37 / $1,485.37 / $2,102.37
| Professional | | $1,485.37 | $1,485.37 | $2,102.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.62 / $1,565.62 / $1,565.62
| Professional | | $1,565.62 | $1,565.62 | $1,565.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.03 / $1,140.05 / $1,717.71
| Professional | | $870.03 | $1,140.05 | $1,717.71 |