- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,843.09 / $1,843.09
| Facility | | $1,400.00 | $1,843.09 | $1,843.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.09 / $1,866.94 / $2,319.06
| Professional | | $1,843.09 | $1,866.94 | $2,319.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,988.54 / $2,192.46 / $2,388.73
| Facility | | $1,988.54 | $2,192.46 | $2,388.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.32 / $2,123.32 / $2,123.32
| Professional | | $2,123.32 | $2,123.32 | $2,123.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,140.42 / $2,140.42 / $2,140.42
| Facility | | $2,140.42 | $2,140.42 | $2,140.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.27 / $2,654.14 / $9,441.84
| Professional | | $1,858.27 | $2,654.14 | $9,441.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.79 / $2,040.91 / $3,075.38
| Professional | | $1,457.79 | $2,040.91 | $3,075.38 |