- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,439.68 / $1,439.68
| Facility | | $1,400.00 | $1,439.68 | $1,439.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.56 / $1,439.68 / $1,676.61
| Professional | | $1,377.56 | $1,439.68 | $1,676.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.31 / $1,735.52 / $1,890.88
| Facility | | $1,516.31 | $1,735.52 | $1,890.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.78 / $1,680.78 / $1,680.78
| Professional | | $1,680.78 | $1,680.78 | $1,680.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,626.62 / $1,626.62 / $1,626.62
| Facility | | $1,626.62 | $1,626.62 | $1,626.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.90 / $2,152.98 / $8,958.93
| Professional | | $1,362.90 | $2,152.98 | $8,958.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.74 / $1,688.26 / $2,444.33
| Professional | | $1,182.74 | $1,688.26 | $2,444.33 |