- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,802.38 / $1,802.38
| Facility | | $1,400.00 | $1,802.38 | $1,802.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.38 / $1,879.60 / $2,071.63
| Professional | | $1,802.38 | $1,879.60 | $2,071.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.82 / $2,074.56 / $2,260.26
| Facility | | $1,794.82 | $2,074.56 | $2,260.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.12 / $2,009.12 / $2,009.12
| Professional | | $2,009.12 | $2,009.12 | $2,009.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,927.82 / $1,927.82 / $1,927.82
| Facility | | $1,927.82 | $1,927.82 | $1,927.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.57 / $2,668.15 / $10,600.48
| Professional | | $1,588.57 | $2,668.15 | $10,600.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.02 / $2,156.21 / $3,334.14
| Professional | | $1,458.02 | $2,156.21 | $3,334.14 |