- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,518.71 / $2,518.71
| Facility | | $1,400.00 | $2,518.71 | $2,518.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.86 / $2,564.71 / $2,970.88
| Professional | | $2,272.86 | $2,564.71 | $2,970.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,534.62 / $2,912.11 / $3,172.80
| Facility | | $2,534.62 | $2,912.11 | $3,172.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,820.26 / $2,820.26 / $2,820.26
| Professional | | $2,820.26 | $2,820.26 | $2,820.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,722.28 / $2,722.28 / $2,722.28
| Facility | | $2,722.28 | $2,722.28 | $2,722.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.40 / $3,607.78 / $13,562.26
| Professional | | $2,264.40 | $3,607.78 | $13,562.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.81 / $2,922.24 / $4,403.42
| Professional | | $1,905.81 | $2,922.24 | $4,403.42 |