- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,504.53 / $3,870.26
| Facility | | $1,400.00 | $2,504.53 | $3,870.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.34 / $2,585.46 / $3,793.94
| Professional | | $2,436.34 | $2,585.46 | $3,793.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,662.98 / $2,997.24 / $3,265.53
| Facility | | $2,662.98 | $2,997.24 | $3,265.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.20 / $2,902.69 / $2,902.69
| Professional | | $1,489.20 | $2,902.69 | $2,902.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,847.41 / $2,847.41 / $2,847.41
| Facility | | $2,847.41 | $2,847.41 | $2,847.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.42 / $2,962.00 / $7,439.93
| Professional | | $2,214.42 | $2,962.00 | $7,439.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.32 / $2,297.88 / $3,762.62
| Professional | | $1,401.32 | $2,297.88 | $3,762.62 |