- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,786.74 / $1,786.74
| Facility | | $1,400.00 | $1,786.74 | $1,786.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.74 / $1,862.96 / $2,055.11
| Professional | | $1,786.74 | $1,862.96 | $2,055.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,779.35 / $2,056.52 / $2,240.62
| Facility | | $1,779.35 | $2,056.52 | $2,240.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.66 / $1,991.66 / $1,991.66
| Professional | | $1,991.66 | $1,991.66 | $1,991.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,910.81 / $1,910.81 / $1,910.81
| Facility | | $1,910.81 | $1,910.81 | $1,910.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,574.97 / $2,644.25 / $10,451.77
| Professional | | $1,574.97 | $2,644.25 | $10,451.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.95 / $2,120.16 / $3,272.20
| Professional | | $1,445.95 | $2,120.16 | $3,272.20 |