- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,185.04 / $3,381.97
| Facility | | $1,400.00 | $2,185.04 | $3,381.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.08 / $2,268.48 / $3,310.57
| Professional | | $1,980.08 | $2,268.48 | $3,310.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,330.42 / $2,619.08 / $2,853.54
| Facility | | $2,330.42 | $2,619.08 | $2,853.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.41 / $2,536.48 / $2,536.48
| Professional | | $1,301.41 | $2,536.48 | $2,536.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,490.91 / $2,490.91 / $2,490.91
| Facility | | $2,490.91 | $2,490.91 | $2,490.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.66 / $3,181.39 / $6,928.56
| Professional | | $2,119.66 | $3,181.39 | $6,928.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.20 / $2,678.68 / $5,222.14
| Professional | | $1,708.20 | $2,678.68 | $5,222.14 |