- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,545.06 / $3,550.00
| Facility | | $1,400.00 | $1,545.06 | $3,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.42 / $1,545.06 / $1,754.54
| Professional | | $1,426.42 | $1,545.06 | $1,754.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.72 / $1,809.13 / $1,971.07
| Facility | | $1,644.72 | $1,809.13 | $1,971.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.06 / $1,752.06 / $1,752.06
| Professional | | $1,752.06 | $1,752.06 | $1,752.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,777.98 / $1,777.98 / $1,777.98
| Facility | | $1,777.98 | $1,777.98 | $1,777.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.02 / $2,190.08 / $7,848.01
| Professional | | $1,544.02 | $2,190.08 | $7,848.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.06 / $1,749.52 / $2,594.34
| Professional | | $1,217.06 | $1,749.52 | $2,594.34 |