- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,752.37 / $1,752.37
| Facility | | $1,400.00 | $1,752.37 | $1,752.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.37 / $1,828.12 / $2,016.12
| Professional | | $1,752.37 | $1,828.12 | $2,016.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,746.08 / $2,017.97 / $2,198.60
| Facility | | $1,746.08 | $2,017.97 | $2,198.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.31 / $1,954.31 / $1,954.31
| Professional | | $1,954.31 | $1,954.31 | $1,954.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.01 / $1,875.01 / $1,875.01
| Facility | | $1,875.01 | $1,875.01 | $1,875.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.76 / $2,576.39 / $8,889.04
| Professional | | $1,545.76 | $2,576.39 | $8,889.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.70 / $2,039.93 / $3,023.90
| Professional | | $1,418.70 | $2,039.93 | $3,023.90 |