- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,025.15 / $3,095.60
| Facility | | $1,400.00 | $2,025.15 | $3,095.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.64 / $2,025.15 / $2,437.92
| Professional | | $1,661.64 | $2,025.15 | $2,437.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,110.64 / $2,397.31 / $2,611.91
| Facility | | $2,110.64 | $2,397.31 | $2,611.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.28 / $2,321.69 / $2,321.69
| Professional | | $1,191.28 | $2,321.69 | $2,321.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,256.13 / $2,256.13 / $2,256.13
| Facility | | $2,256.13 | $2,256.13 | $2,256.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.53 / $2,536.50 / $5,032.43
| Professional | | $1,644.53 | $2,536.50 | $5,032.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.00 / $765.00 / $765.00
| Facility | | $765.00 | $765.00 | $765.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.00 / $2,054.71 / $3,095.60
| Professional | | $1,512.00 | $2,054.71 | $3,095.60 |