- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,867.62 / $1,867.62
| Facility | | $1,400.00 | $1,867.62 | $1,867.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.62 / $1,982.60 / $2,233.78
| Professional | | $1,867.62 | $1,982.60 | $2,233.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,893.19 / $2,166.56 / $2,360.50
| Facility | | $1,893.19 | $2,166.56 | $2,360.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.21 / $2,098.21 / $2,098.21
| Professional | | $2,098.21 | $2,098.21 | $2,098.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,030.86 / $2,030.86 / $2,030.86
| Facility | | $2,030.86 | $2,030.86 | $2,030.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.85 / $2,685.68 / $17,007.07
| Professional | | $1,701.85 | $2,685.68 | $17,007.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.94 / $2,157.17 / $3,350.48
| Professional | | $1,474.94 | $2,157.17 | $3,350.48 |