- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,507.48 / $1,507.48
| Facility | | $1,400.00 | $1,507.48 | $1,507.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.48 / $1,588.52 / $1,792.55
| Professional | | $1,507.48 | $1,588.52 | $1,792.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.48 / $1,734.44 / $1,889.70
| Facility | | $1,520.48 | $1,734.44 | $1,889.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.74 / $1,679.74 / $1,679.74
| Professional | | $1,679.74 | $1,679.74 | $1,679.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,628.71 / $1,628.71 / $1,628.71
| Facility | | $1,628.71 | $1,628.71 | $1,628.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.56 / $2,099.67 / $7,948.99
| Professional | | $1,368.56 | $2,099.67 | $7,948.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.02 / $1,567.75 / $2,524.96
| Professional | | $1,160.02 | $1,567.75 | $2,524.96 |