- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,057.27 / $3,126.75
| Facility | | $1,400.00 | $2,057.27 | $3,126.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.12 / $2,057.27 / $2,458.30
| Professional | | $1,743.12 | $2,057.27 | $2,458.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,118.23 / $2,421.44 / $2,638.20
| Facility | | $2,118.23 | $2,421.44 | $2,638.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.03 / $2,345.06 / $2,345.06
| Professional | | $1,203.03 | $2,345.06 | $2,345.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,270.62 / $2,270.62 / $2,270.62
| Facility | | $2,270.62 | $2,270.62 | $2,270.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.91 / $2,710.69 / $5,663.62
| Professional | | $1,760.91 | $2,710.69 | $5,663.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.91 / $2,147.63 / $3,240.20
| Professional | | $1,561.91 | $2,147.63 | $3,240.20 |