- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $4,448.01 / $6,770.37
| Facility | | $1,400.00 | $4,448.01 | $6,770.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,868.14 / $4,448.01 / $6,081.96
| Professional | | $3,868.14 | $4,448.01 | $6,081.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,566.47 / $5,243.16 / $5,712.50
| Facility | | $4,566.47 | $5,243.16 | $5,712.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,605.19 / $5,077.78 / $5,077.78
| Professional | | $2,605.19 | $5,077.78 | $5,077.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,904.50 / $4,904.50 / $4,904.50
| Facility | | $4,904.50 | $4,904.50 | $4,904.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,444.13 / $5,924.07 / $13,007.15
| Professional | | $3,444.13 | $5,924.07 | $13,007.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.08 / $4,129.39 / $6,770.37
| Professional | | $2,707.08 | $4,129.39 | $6,770.37 |