- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,479.44 / $1,479.44
| Facility | | $1,400.00 | $1,479.44 | $1,479.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.58 / $1,513.56 / $1,763.22
| Professional | | $1,274.58 | $1,513.56 | $1,763.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.87 / $1,710.58 / $1,863.70
| Facility | | $1,493.87 | $1,710.58 | $1,863.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.62 / $1,656.62 / $1,656.62
| Professional | | $1,656.62 | $1,656.62 | $1,656.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.28 / $1,604.28 / $1,604.28
| Facility | | $1,604.28 | $1,604.28 | $1,604.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.43 / $2,135.55 / $9,390.43
| Professional | | $1,341.43 | $2,135.55 | $9,390.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.77 / $1,707.41 / $2,660.07
| Professional | | $1,147.77 | $1,707.41 | $2,660.07 |