- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,786.30 / $1,786.30
| Facility | | $1,400.00 | $1,786.30 | $1,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.69 / $1,786.30 / $2,144.69
| Professional | | $1,621.69 | $1,786.30 | $2,144.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,020.87 / $2,355.61 / $2,566.46
| Facility | | $2,020.87 | $2,355.61 | $2,566.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.31 / $2,281.31 / $2,281.31
| Professional | | $2,281.31 | $2,281.31 | $2,281.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,166.29 / $2,166.29 / $2,166.29
| Facility | | $2,166.29 | $2,166.29 | $2,166.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.31 / $2,851.64 / $9,636.46
| Professional | | $1,820.31 | $2,851.64 | $9,636.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.87 / $2,258.83 / $3,041.74
| Professional | | $1,520.87 | $2,258.83 | $3,041.74 |