- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,784.71 / $1,784.71
| Facility | | $1,400.00 | $1,784.71 | $1,784.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.08 / $1,799.36 / $1,995.93
| Professional | | $1,610.08 | $1,799.36 | $1,995.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,866.36 / $2,072.92 / $2,258.48
| Facility | | $1,866.36 | $2,072.92 | $2,258.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.54 / $2,007.54 / $2,007.54
| Professional | | $2,007.54 | $2,007.54 | $2,007.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,997.03 / $1,997.03 / $1,997.03
| Facility | | $1,997.03 | $1,997.03 | $1,997.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,703.87 / $2,509.42 / $10,466.44
| Professional | | $1,703.87 | $2,509.42 | $10,466.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.52 / $2,049.60 / $3,128.78
| Professional | | $1,438.52 | $2,049.60 | $3,128.78 |