- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,042.94 / $2,042.94
| Facility | | $1,400.00 | $2,042.94 | $2,042.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.85 / $2,042.94 / $2,371.44
| Professional | | $1,951.85 | $2,042.94 | $2,371.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.83 / $2,460.55 / $2,680.80
| Facility | | $2,147.83 | $2,460.55 | $2,680.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.94 / $2,382.94 / $2,382.94
| Professional | | $2,382.94 | $2,382.94 | $2,382.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,306.71 / $2,306.71 / $2,306.71
| Facility | | $2,306.71 | $2,306.71 | $2,306.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.47 / $3,044.66 / $11,621.10
| Professional | | $1,927.47 | $3,044.66 | $11,621.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.30 / $2,822.54 / $5,192.20
| Professional | | $1,676.30 | $2,822.54 | $5,192.20 |