- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,484.11 / $2,484.11
| Facility | | $1,400.00 | $2,484.11 | $2,484.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.31 / $2,735.83 / $3,032.19
| Professional | | $2,302.31 | $2,735.83 | $3,032.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,208.72 / $3,727.63 / $4,061.31
| Facility | | $3,208.72 | $3,727.63 | $4,061.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,610.06 / $3,610.06 / $3,610.06
| Professional | | $3,610.06 | $3,610.06 | $3,610.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.08 / $3,453.08 / $3,453.08
| Facility | | $3,453.08 | $3,453.08 | $3,453.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.61 / $4,512.56 / $14,365.58
| Professional | | $2,902.61 | $4,512.56 | $14,365.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.98 / $3,090.77 / $4,421.33
| Professional | | $2,190.98 | $3,090.77 | $4,421.33 |