- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,703.01 / $4,053.76
| Facility | | $1,400.00 | $2,703.01 | $4,053.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.84 / $2,703.01 / $3,346.85
| Professional | | $2,512.84 | $2,703.01 | $3,346.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,616.12 / $2,843.25 / $3,420.36
| Facility | | $2,616.12 | $2,843.25 | $3,420.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.69 / $3,040.32 / $3,040.32
| Professional | | $1,559.69 | $3,040.32 | $3,040.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,064.82 / $3,064.82 / $3,064.82
| Facility | | $3,064.82 | $3,064.82 | $3,064.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.42 / $3,547.05 / $7,652.16
| Professional | | $2,203.42 | $3,547.05 | $7,652.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.60 / $2,895.18 / $4,408.87
| Professional | | $2,117.60 | $2,895.18 | $4,408.87 |