- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $3,376.27 / $5,174.89
| Facility | | $1,400.00 | $3,376.27 | $5,174.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,286.64 / $3,537.20 / $5,094.55
| Professional | | $3,286.64 | $3,537.20 | $5,094.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,576.36 / $4,007.58 / $4,366.32
| Facility | | $3,576.36 | $4,007.58 | $4,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.23 / $3,881.17 / $3,881.17
| Professional | | $1,991.23 | $3,881.17 | $3,881.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,837.41 / $3,837.41 / $3,837.41
| Facility | | $3,837.41 | $3,837.41 | $3,837.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,271.99 / $4,624.89 / $9,333.50
| Professional | | $3,271.99 | $4,624.89 | $9,333.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.67 / $3,902.34 / $6,566.86
| Professional | | $2,273.67 | $3,902.34 | $6,566.86 |