- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,978.09 / $1,978.09
| Facility | | $1,400.00 | $1,978.09 | $1,978.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.70 / $1,978.09 / $2,366.86
| Professional | | $1,797.70 | $1,978.09 | $2,366.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,239.73 / $2,608.73 / $2,842.26
| Facility | | $2,239.73 | $2,608.73 | $2,842.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,526.46 / $2,526.46 / $2,526.46
| Professional | | $2,526.46 | $2,526.46 | $2,526.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.06 / $2,400.06 / $2,400.06
| Facility | | $2,400.06 | $2,400.06 | $2,400.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,019.47 / $3,158.07 / $10,416.87
| Professional | | $2,019.47 | $3,158.07 | $10,416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.59 / $2,386.58 / $3,368.61
| Professional | | $1,629.59 | $2,386.58 | $3,368.61 |