- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $4,612.34 / $7,018.85
| Facility | | $1,400.00 | $4,612.34 | $7,018.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,942.03 / $4,612.34 / $5,504.71
| Professional | | $3,942.03 | $4,612.34 | $5,504.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,733.46 / $5,435.58 / $5,922.15
| Facility | | $4,733.46 | $5,435.58 | $5,922.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,700.79 / $5,264.14 / $5,264.14
| Professional | | $2,700.79 | $5,264.14 | $5,264.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,083.51 / $5,083.51 / $5,083.51
| Facility | | $5,083.51 | $5,083.51 | $5,083.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,569.48 / $6,141.49 / $13,595.38
| Professional | | $3,569.48 | $6,141.49 | $13,595.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.89 / $4,046.19 / $7,018.85
| Professional | | $2,451.89 | $4,046.19 | $7,018.85 |