- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,139.54 / $2,139.54
| Facility | | $1,400.00 | $2,139.54 | $2,139.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.58 / $2,179.80 / $2,526.67
| Professional | | $1,961.58 | $2,179.80 | $2,526.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,153.92 / $2,473.67 / $2,695.11
| Facility | | $2,153.92 | $2,473.67 | $2,695.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.66 / $2,395.66 / $2,395.66
| Professional | | $2,395.66 | $2,395.66 | $2,395.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,313.62 / $2,313.62 / $2,313.62
| Facility | | $2,313.62 | $2,313.62 | $2,313.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.42 / $3,026.31 / $12,807.64
| Professional | | $1,925.42 | $3,026.31 | $12,807.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.91 / $2,715.31 / $4,028.38
| Professional | | $1,659.91 | $2,715.31 | $4,028.38 |