- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,390.62 / $2,390.62
| Facility | | $1,400.00 | $2,390.62 | $2,390.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.35 / $2,390.62 / $2,770.73
| Professional | | $2,282.35 | $2,390.62 | $2,770.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,512.08 / $2,879.33 / $3,137.08
| Facility | | $2,512.08 | $2,879.33 | $3,137.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,788.51 / $2,788.51 / $2,788.51
| Professional | | $2,788.51 | $2,788.51 | $2,788.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,696.98 / $2,696.98 / $2,696.98
| Facility | | $2,696.98 | $2,696.98 | $2,696.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.67 / $3,485.64 / $11,024.40
| Professional | | $2,252.67 | $3,485.64 | $11,024.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.61 / $2,491.32 / $3,797.73
| Professional | | $1,837.61 | $2,491.32 | $3,797.73 |