- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,602.06 / $1,602.06
| Facility | | $1,400.00 | $1,602.06 | $1,602.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.06 / $1,700.66 / $1,892.92
| Professional | | $1,602.06 | $1,700.66 | $1,892.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,623.20 / $1,851.66 / $2,017.41
| Facility | | $1,623.20 | $1,851.66 | $2,017.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.26 / $1,793.26 / $1,793.26
| Professional | | $1,793.26 | $1,793.26 | $1,793.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.02 / $1,744.02 / $1,744.02
| Facility | | $1,744.02 | $1,744.02 | $1,744.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.04 / $2,293.81 / $9,138.86
| Professional | | $1,459.04 | $2,293.81 | $9,138.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.67 / $1,912.13 / $2,831.55
| Professional | | $1,261.67 | $1,912.13 | $2,831.55 |