- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,968.78 / $1,968.78
| Facility | | $1,400.00 | $1,968.78 | $1,968.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.07 / $1,992.04 / $2,472.39
| Professional | | $1,968.07 | $1,992.04 | $2,472.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,121.75 / $2,340.29 / $2,549.79
| Facility | | $2,121.75 | $2,340.29 | $2,549.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.48 / $2,266.48 / $2,266.48
| Professional | | $2,266.48 | $2,266.48 | $2,266.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,284.13 / $2,284.13 / $2,284.13
| Facility | | $2,284.13 | $2,284.13 | $2,284.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.23 / $2,833.09 / $10,167.14
| Professional | | $1,981.23 | $2,833.09 | $10,167.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.84 / $2,216.38 / $3,285.87
| Professional | | $1,538.84 | $2,216.38 | $3,285.87 |