- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,004.29 / $2,004.29
| Facility | | $1,400.00 | $2,004.29 | $2,004.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.29 / $2,089.78 / $2,301.75
| Professional | | $2,004.29 | $2,089.78 | $2,301.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.49 / $2,307.53 / $2,514.09
| Facility | | $1,995.49 | $2,307.53 | $2,514.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.75 / $2,234.75 / $2,234.75
| Professional | | $2,234.75 | $2,234.75 | $2,234.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,143.44 / $2,143.44 / $2,143.44
| Facility | | $2,143.44 | $2,143.44 | $2,143.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.13 / $2,967.86 / $11,922.57
| Professional | | $1,765.13 | $2,967.86 | $11,922.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.57 / $2,332.44 / $3,631.27
| Professional | | $1,622.57 | $2,332.44 | $3,631.27 |