- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,695.06 / $1,695.06
| Facility | | $1,400.00 | $1,695.06 | $1,695.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.80 / $1,695.06 / $2,025.53
| Professional | | $1,539.80 | $1,695.06 | $2,025.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,918.49 / $2,235.46 / $2,435.56
| Facility | | $1,918.49 | $2,235.46 | $2,435.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.94 / $2,164.94 / $2,164.94
| Professional | | $2,164.94 | $2,164.94 | $2,164.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.42 / $2,056.42 / $2,056.42
| Facility | | $2,056.42 | $2,056.42 | $2,056.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.04 / $2,706.18 / $9,972.51
| Professional | | $1,729.04 | $2,706.18 | $9,972.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.25 / $2,049.04 / $2,886.59
| Professional | | $1,356.25 | $2,049.04 | $2,886.59 |