- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,057.80 / $2,057.80
| Facility | | $1,400.00 | $2,057.80 | $2,057.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.80 / $2,168.07 / $2,424.14
| Professional | | $2,057.80 | $2,168.07 | $2,424.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,067.19 / $2,375.21 / $2,587.83
| Facility | | $2,067.19 | $2,375.21 | $2,587.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.29 / $2,300.29 / $2,300.29
| Professional | | $2,300.29 | $2,300.29 | $2,300.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,222.06 / $2,222.06 / $2,222.06
| Facility | | $2,222.06 | $2,222.06 | $2,222.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.21 / $2,875.74 / $17,691.98
| Professional | | $1,846.21 | $2,875.74 | $17,691.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.04 / $2,394.38 / $3,520.21
| Professional | | $1,600.04 | $2,394.38 | $3,520.21 |