- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,874.37 / $4,886.53
| Facility | | $1,400.00 | $2,874.37 | $4,886.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,757.23 / $3,139.02 / $5,153.38
| Professional | | $2,757.23 | $3,139.02 | $5,153.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,234.84 / $3,784.25 / $4,123.01
| Facility | | $3,234.84 | $3,784.25 | $4,123.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.31 / $3,664.90 / $3,664.90
| Professional | | $1,880.31 | $3,664.90 | $3,664.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.26 / $3,468.26 / $3,468.26
| Facility | | $3,468.26 | $3,468.26 | $3,468.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.53 / $4,317.68 / $9,445.56
| Professional | | $2,900.53 | $4,317.68 | $9,445.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.17 / $3,686.68 / $4,886.53
| Professional | | $2,285.17 | $3,686.68 | $4,886.53 |