- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,730.33 / $1,730.33
| Facility | | $1,400.00 | $1,730.33 | $1,730.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.53 / $1,776.52 / $2,070.50
| Professional | | $1,510.53 | $1,776.52 | $2,070.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,754.16 / $2,007.06 / $2,186.73
| Facility | | $1,754.16 | $2,007.06 | $2,186.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.76 / $1,943.76 / $1,943.76
| Professional | | $1,943.76 | $1,943.76 | $1,943.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,882.68 / $1,882.68 / $1,882.68
| Facility | | $1,882.68 | $1,882.68 | $1,882.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.33 / $2,463.08 / $10,859.41
| Professional | | $1,577.33 | $2,463.08 | $10,859.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.62 / $1,930.62 / $3,058.69
| Professional | | $1,363.62 | $1,930.62 | $3,058.69 |