- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,353.40 / $2,353.40
| Facility | | $1,400.00 | $2,353.40 | $2,353.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.50 / $2,353.40 / $3,080.29
| Professional | | $1,487.50 | $2,353.40 | $3,080.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.50 / $1,788.50 / $2,182.92
| Facility | | $1,788.50 | $1,788.50 | $2,182.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.38 / $1,940.38 / $1,940.38
| Professional | | $1,940.38 | $1,940.38 | $1,940.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,588.77 / $2,588.77 / $2,588.77
| Facility | | $2,588.77 | $2,588.77 | $2,588.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.96 / $2,446.79 / $5,741.34
| Professional | | $1,496.96 | $2,446.79 | $5,741.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.17 / $2,146.82 / $3,818.50
| Professional | | $1,396.17 | $2,146.82 | $3,818.50 |