- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,929.27 / $2,932.53
| Facility | | $1,400.00 | $1,929.27 | $2,932.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.86 / $1,929.27 / $2,306.48
| Professional | | $1,624.86 | $1,929.27 | $2,306.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.95 / $2,271.04 / $2,474.32
| Facility | | $1,987.95 | $2,271.04 | $2,474.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.34 / $2,199.40 / $2,199.40
| Professional | | $1,128.34 | $2,199.40 | $2,199.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,130.71 / $2,130.71 / $2,130.71
| Facility | | $2,130.71 | $2,130.71 | $2,130.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.56 / $2,536.10 / $5,285.50
| Professional | | $1,629.56 | $2,536.10 | $5,285.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.26 / $1,979.46 / $3,043.29
| Professional | | $1,466.26 | $1,979.46 | $3,043.29 |