- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,798.33 / $3,063.52
| Facility | | $1,400.00 | $1,798.33 | $3,063.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.33 / $1,985.53 / $3,214.81
| Professional | | $1,798.33 | $1,985.53 | $3,214.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,036.95 / $2,372.46 / $2,584.85
| Facility | | $2,036.95 | $2,372.46 | $2,584.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.93 / $2,297.64 / $2,297.64
| Professional | | $1,178.93 | $2,297.64 | $2,297.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.87 / $2,182.87 / $2,182.87
| Facility | | $2,182.87 | $2,182.87 | $2,182.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.68 / $2,680.58 / $5,858.91
| Professional | | $1,836.68 | $2,680.58 | $5,858.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.67 / $2,097.59 / $3,104.80
| Professional | | $1,480.67 | $2,097.59 | $3,104.80 |