- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,556.16 / $3,919.70
| Facility | | $1,400.00 | $2,556.16 | $3,919.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,528.56 / $2,659.19 / $3,919.80
| Professional | | $2,528.56 | $2,659.19 | $3,919.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,729.40 / $3,035.52 / $3,307.24
| Facility | | $2,729.40 | $3,035.52 | $3,307.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.32 / $2,939.77 / $2,939.77
| Professional | | $1,508.32 | $2,939.77 | $2,939.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,934.56 / $2,934.56 / $2,934.56
| Facility | | $2,934.56 | $2,934.56 | $2,934.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,494.63 / $3,905.09 / $6,941.36
| Professional | | $2,494.63 | $3,905.09 | $6,941.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.13 / $3,219.67 / $4,688.92
| Professional | | $2,090.13 | $3,219.67 | $4,688.92 |