- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $3,820.73 / $5,828.13
| Facility | | $1,400.00 | $3,820.73 | $5,828.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,472.26 / $3,820.73 / $4,580.96
| Professional | | $3,472.26 | $3,820.73 | $4,580.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.37 / $4,513.46 / $4,917.47
| Facility | | $3,943.37 | $4,513.46 | $4,917.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,242.56 / $4,371.10 / $4,371.10
| Professional | | $2,242.56 | $4,371.10 | $4,371.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,232.83 / $4,232.83 / $4,232.83
| Facility | | $4,232.83 | $4,232.83 | $4,232.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,488.95 / $5,207.54 / $10,608.40
| Professional | | $3,488.95 | $5,207.54 | $10,608.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,080.93 / $4,542.39 / $6,775.96
| Professional | | $3,080.93 | $4,542.39 | $6,775.96 |