- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,297.26 / $3,488.18
| Facility | | $1,400.00 | $2,297.26 | $3,488.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.32 / $2,297.26 / $2,749.52
| Professional | | $1,932.32 | $2,297.26 | $2,749.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,367.87 / $2,701.34 / $2,943.15
| Facility | | $2,367.87 | $2,701.34 | $2,943.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.23 / $2,616.13 / $2,616.13
| Professional | | $1,342.23 | $2,616.13 | $2,616.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.38 / $2,540.38 / $2,540.38
| Facility | | $2,540.38 | $2,540.38 | $2,540.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.29 / $3,024.29 / $5,936.71
| Professional | | $2,025.29 | $3,024.29 | $5,936.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.09 / $2,489.91 / $3,639.09
| Professional | | $1,744.09 | $2,489.91 | $3,639.09 |