- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,586.87 / $1,586.87
| Facility | | $1,400.00 | $1,586.87 | $1,586.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.81 / $1,586.87 / $1,906.80
| Professional | | $1,447.81 | $1,586.87 | $1,906.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,804.37 / $2,095.40 / $2,282.96
| Facility | | $1,804.37 | $2,095.40 | $2,282.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.31 / $2,029.31 / $2,029.31
| Professional | | $2,029.31 | $2,029.31 | $2,029.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.89 / $1,932.89 / $1,932.89
| Facility | | $1,932.89 | $1,932.89 | $1,932.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.11 / $2,383.87 / $8,220.75
| Professional | | $1,550.11 | $2,383.87 | $8,220.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.18 / $1,826.38 / $2,705.74
| Professional | | $1,213.18 | $1,826.38 | $2,705.74 |