- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,861.21 / $2,836.46
| Facility | | $1,400.00 | $1,861.21 | $2,836.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.81 / $1,861.21 / $2,227.52
| Professional | | $1,556.81 | $1,861.21 | $2,227.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,923.29 / $2,196.64 / $2,393.27
| Facility | | $1,923.29 | $2,196.64 | $2,393.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.50 / $2,127.35 / $2,127.35
| Professional | | $1,091.50 | $2,127.35 | $2,127.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.11 / $2,060.11 / $2,060.11
| Facility | | $2,060.11 | $2,060.11 | $2,060.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.38 / $2,436.62 / $5,042.39
| Professional | | $1,575.38 | $2,436.62 | $5,042.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.83 / $1,914.61 / $2,926.60
| Professional | | $1,367.83 | $1,914.61 | $2,926.60 |