- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,379.55 / $3,619.81
| Facility | | $1,400.00 | $2,379.55 | $3,619.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,024.50 / $2,379.55 / $2,840.06
| Professional | | $2,024.50 | $2,379.55 | $2,840.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.96 / $2,803.27 / $3,054.21
| Facility | | $2,448.96 | $2,803.27 | $3,054.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.81 / $2,714.86 / $2,714.86
| Professional | | $1,392.81 | $2,714.86 | $2,714.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,624.83 / $2,624.83 / $2,624.83
| Facility | | $2,624.83 | $2,624.83 | $2,624.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.83 / $3,122.29 / $6,538.21
| Professional | | $2,041.83 | $3,122.29 | $6,538.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.40 / $2,668.46 / $4,202.18
| Professional | | $1,819.40 | $2,668.46 | $4,202.18 |