- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,296.46 / $3,502.10
| Facility | | $1,400.00 | $2,296.46 | $3,502.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.01 / $2,296.46 / $2,748.55
| Professional | | $2,085.01 | $2,296.46 | $2,748.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,712.12 / $2,712.12 / $2,954.89
| Facility | | $2,712.12 | $2,712.12 | $2,954.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.60 / $2,626.57 / $2,626.57
| Professional | | $1,347.60 | $2,626.57 | $2,626.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,543.44 / $2,543.44 / $2,543.44
| Facility | | $2,543.44 | $2,543.44 | $2,543.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.98 / $3,154.38 / $6,754.94
| Professional | | $2,094.98 | $3,154.38 | $6,754.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.37 / $2,536.33 / $3,964.94
| Professional | | $1,785.37 | $2,536.33 | $3,964.94 |