- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,215.75 / $3,365.82
| Facility | | $1,400.00 | $2,215.75 | $3,365.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.51 / $2,215.75 / $2,646.52
| Professional | | $1,842.51 | $2,215.75 | $2,646.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,279.96 / $2,606.58 / $2,839.91
| Facility | | $2,279.96 | $2,606.58 | $2,839.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.23 / $2,524.37 / $2,524.37
| Professional | | $1,295.23 | $2,524.37 | $2,524.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,445.40 / $2,445.40 / $2,445.40
| Facility | | $2,445.40 | $2,445.40 | $2,445.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.84 / $2,932.22 / $6,127.86
| Professional | | $1,846.84 | $2,932.22 | $6,127.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.46 / $2,483.73 / $3,414.30
| Professional | | $1,693.46 | $2,483.73 | $3,414.30 |