- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,607.64 / $1,607.64
| Facility | | $1,400.00 | $1,607.64 | $1,607.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.64 / $1,678.92 / $3,361.79
| Professional | | $1,607.64 | $1,678.92 | $3,361.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,602.43 / $1,851.36 / $2,017.08
| Facility | | $1,602.43 | $1,851.36 | $2,017.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.96 / $1,792.96 / $1,792.96
| Professional | | $1,792.96 | $1,792.96 | $1,792.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.84 / $1,721.84 / $1,721.84
| Facility | | $1,721.84 | $1,721.84 | $1,721.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.23 / $2,382.40 / $9,405.10
| Professional | | $1,419.23 | $2,382.40 | $9,405.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.21 / $1,870.49 / $2,718.78
| Professional | | $1,301.21 | $1,870.49 | $2,718.78 |