- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,769.31 / $1,769.31
| Facility | | $1,400.00 | $1,769.31 | $1,769.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.64 / $1,769.31 / $2,112.75
| Professional | | $1,606.64 | $1,769.31 | $2,112.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.82 / $2,331.86 / $2,540.59
| Facility | | $2,000.82 | $2,331.86 | $2,540.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,258.30 / $2,258.30 / $2,258.30
| Professional | | $2,258.30 | $2,258.30 | $2,258.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.77 / $2,145.77 / $2,145.77
| Facility | | $2,145.77 | $2,145.77 | $2,145.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.53 / $2,822.89 / $9,489.58
| Professional | | $1,802.53 | $2,822.89 | $9,489.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.54 / $2,032.47 / $3,011.07
| Professional | | $1,505.54 | $2,032.47 | $3,011.07 |