- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,453.25 / $1,453.25
| Facility | | $1,400.00 | $1,453.25 | $1,453.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.09 / $1,453.25 / $1,733.83
| Professional | | $1,322.09 | $1,453.25 | $1,733.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.42 / $1,914.86 / $2,086.28
| Facility | | $1,645.42 | $1,914.86 | $2,086.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.47 / $1,854.47 / $1,854.47
| Professional | | $1,854.47 | $1,854.47 | $1,854.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.56 / $1,763.56 / $1,763.56
| Facility | | $1,763.56 | $1,763.56 | $1,763.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.13 / $2,318.08 / $11,724.26
| Professional | | $1,485.13 | $2,318.08 | $11,724.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.31 / $1,750.44 / $2,472.62
| Professional | | $1,236.31 | $1,750.44 | $2,472.62 |