- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,974.07 / $4,510.24
| Facility | | $1,400.00 | $2,974.07 | $4,510.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.19 / $2,974.07 / $3,552.01
| Professional | | $2,527.19 | $2,974.07 | $3,552.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,055.72 / $3,492.85 / $3,805.52
| Facility | | $3,055.72 | $3,492.85 | $3,805.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.54 / $3,382.68 / $3,382.68
| Professional | | $1,735.54 | $3,382.68 | $3,382.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,279.28 / $3,279.28 / $3,279.28
| Facility | | $3,279.28 | $3,279.28 | $3,279.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,553.51 / $3,911.06 / $8,186.77
| Professional | | $2,553.51 | $3,911.06 | $8,186.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.76 / $3,221.44 / $4,689.33
| Professional | | $2,181.76 | $3,221.44 | $4,689.33 |