- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,816.90 / $4,359.66
| Facility | | $1,400.00 | $2,816.90 | $4,359.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.88 / $2,920.27 / $3,576.09
| Professional | | $2,746.88 | $2,920.27 | $3,576.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,002.49 / $3,376.25 / $3,678.47
| Facility | | $3,002.49 | $3,376.25 | $3,678.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.39 / $3,269.75 / $3,269.75
| Professional | | $1,677.39 | $3,269.75 | $3,269.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,209.63 / $3,209.63 / $3,209.63
| Facility | | $3,209.63 | $3,209.63 | $3,209.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,730.43 / $3,814.71 / $6,615.42
| Professional | | $2,730.43 | $3,814.71 | $6,615.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.65 / $3,098.12 / $6,141.36
| Professional | | $2,169.65 | $3,098.12 | $6,141.36 |