- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,855.68 / $2,855.68
| Facility | | $1,400.00 | $2,855.68 | $2,855.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,834.85 / $2,878.93 / $3,529.16
| Professional | | $2,834.85 | $2,878.93 | $3,529.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,065.88 / $3,394.84 / $3,698.73
| Facility | | $3,065.88 | $3,394.84 | $3,698.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,287.76 / $3,287.76 / $3,287.76
| Professional | | $3,287.76 | $3,287.76 | $3,287.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,305.09 / $3,305.09 / $3,305.09
| Facility | | $3,305.09 | $3,305.09 | $3,305.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,841.72 / $4,109.70 / $14,996.41
| Professional | | $2,841.72 | $4,109.70 | $14,996.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,246.08 / $3,197.10 / $4,772.16
| Professional | | $2,246.08 | $3,197.10 | $4,772.16 |