- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,976.02 / $4,547.30
| Facility | | $1,400.00 | $2,976.02 | $4,547.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.89 / $2,976.02 / $3,565.03
| Professional | | $2,480.89 | $2,976.02 | $3,565.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,083.72 / $3,521.54 / $3,836.78
| Facility | | $3,083.72 | $3,521.54 | $3,836.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,749.68 / $3,410.47 / $3,410.47
| Professional | | $1,749.68 | $3,410.47 | $3,410.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,301.00 / $3,301.00 / $3,301.00
| Facility | | $3,301.00 | $3,301.00 | $3,301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.28 / $3,836.81 / $7,575.49
| Professional | | $2,551.28 | $3,836.81 | $7,575.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.92 / $3,195.90 / $4,556.68
| Professional | | $2,215.92 | $3,195.90 | $4,556.68 |