- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,261.67 / $2,261.67
| Facility | | $1,400.00 | $2,261.67 | $2,261.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.67 / $2,392.44 / $2,710.38
| Professional | | $2,261.67 | $2,392.44 | $2,710.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,284.71 / $2,614.87 / $2,848.95
| Facility | | $2,284.71 | $2,614.87 | $2,848.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.40 / $2,532.40 / $2,532.40
| Professional | | $2,532.40 | $2,532.40 | $2,532.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.42 / $2,448.42 / $2,448.42
| Facility | | $2,448.42 | $2,448.42 | $2,448.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.36 / $3,055.52 / $10,073.37
| Professional | | $2,058.36 | $3,055.52 | $10,073.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.78 / $1,926.92 / $3,485.12
| Professional | | $1,412.78 | $1,926.92 | $3,485.12 |