- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,197.01 / $3,374.35
| Facility | | $1,400.00 | $2,197.01 | $3,374.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,176.44 / $2,338.21 / $2,909.56
| Professional | | $2,176.44 | $2,338.21 | $2,909.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,349.01 / $2,613.17 / $2,847.11
| Facility | | $2,349.01 | $2,613.17 | $2,847.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.22 / $2,530.76 / $2,530.76
| Professional | | $1,298.22 | $2,530.76 | $2,530.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,513.88 / $2,513.88 / $2,513.88
| Facility | | $2,513.88 | $2,513.88 | $2,513.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.13 / $2,794.26 / $5,334.77
| Professional | | $2,146.13 | $2,794.26 | $5,334.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.24 / $2,495.87 / $3,374.35
| Professional | | $1,610.24 | $2,495.87 | $3,374.35 |