- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,915.43 / $2,915.43
| Facility | | $1,400.00 | $2,915.43 | $2,915.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.90 / $2,915.43 / $3,525.56
| Professional | | $2,632.90 | $2,915.43 | $3,525.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,277.96 / $3,837.29 / $4,180.77
| Facility | | $3,277.96 | $3,837.29 | $4,180.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,716.24 / $3,716.24 / $3,716.24
| Professional | | $3,716.24 | $3,716.24 | $3,716.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,516.10 / $3,516.10 / $3,516.10
| Facility | | $3,516.10 | $3,516.10 | $3,516.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,936.69 / $4,645.31 / $17,084.18
| Professional | | $2,936.69 | $4,645.31 | $17,084.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.42 / $3,458.72 / $4,957.12
| Professional | | $2,460.42 | $3,458.72 | $4,957.12 |