- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,574.28 / $2,389.87
| Facility | | $1,400.00 | $1,574.28 | $2,389.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.14 / $1,574.28 / $1,886.97
| Professional | | $1,310.14 | $1,574.28 | $1,886.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,627.03 / $1,850.78 / $2,016.45
| Facility | | $1,627.03 | $1,850.78 | $2,016.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.64 / $1,792.40 / $1,792.40
| Professional | | $919.64 | $1,792.40 | $1,792.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,742.32 / $1,742.32 / $1,742.32
| Facility | | $1,742.32 | $1,742.32 | $1,742.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.22 / $1,975.89 / $3,846.09
| Professional | | $1,273.22 | $1,975.89 | $3,846.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.35 / $1,590.97 / $2,471.51
| Professional | | $1,175.35 | $1,590.97 | $2,471.51 |