- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,035.30 / $2,035.30
| Facility | | $1,400.00 | $2,035.30 | $2,035.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.85 / $2,035.30 / $2,430.35
| Professional | | $1,844.85 | $2,035.30 | $2,430.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,298.91 / $2,683.57 / $2,923.79
| Facility | | $2,298.91 | $2,683.57 | $2,923.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,598.92 / $2,598.92 / $2,598.92
| Professional | | $2,598.92 | $2,598.92 | $2,598.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.73 / $2,463.73 / $2,463.73
| Facility | | $2,463.73 | $2,463.73 | $2,463.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.13 / $3,248.66 / $11,303.77
| Professional | | $2,067.13 | $3,248.66 | $11,303.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.62 / $2,465.82 / $3,465.23
| Professional | | $1,732.62 | $2,465.82 | $3,465.23 |