- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,609.42 / $4,014.72
| Facility | | $1,400.00 | $2,609.42 | $4,014.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,316.78 / $2,609.42 / $3,125.57
| Professional | | $2,316.78 | $2,609.42 | $3,125.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,720.58 / $3,109.12 / $3,387.42
| Facility | | $2,720.58 | $3,109.12 | $3,387.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.76 / $3,011.04 / $3,011.04
| Professional | | $1,544.76 | $3,011.04 | $3,011.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,910.22 / $2,910.22 / $2,910.22
| Facility | | $2,910.22 | $2,910.22 | $2,910.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.32 / $3,508.71 / $7,350.94
| Professional | | $2,349.32 | $3,508.71 | $7,350.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.86 / $2,862.15 / $4,131.10
| Professional | | $2,004.86 | $2,862.15 | $4,131.10 |