- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,181.82 / $3,352.96
| Facility | | $1,400.00 | $2,181.82 | $3,352.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.22 / $2,285.08 / $3,149.87
| Professional | | $2,001.22 | $2,285.08 | $3,149.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,323.86 / $2,596.62 / $2,829.06
| Facility | | $2,323.86 | $2,596.62 | $2,829.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.06 / $2,514.71 / $2,514.71
| Professional | | $1,290.06 | $2,514.71 | $2,514.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,486.26 / $2,486.26 / $2,486.26
| Facility | | $2,486.26 | $2,486.26 | $2,486.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.04 / $3,097.35 / $7,002.80
| Professional | | $2,118.04 | $3,097.35 | $7,002.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,522.00 / $3,522.00 / $3,522.00
| Facility | | $3,522.00 | $3,522.00 | $3,522.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.83 / $2,531.89 / $3,559.46
| Professional | | $1,655.83 | $2,531.89 | $3,559.46 |