- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,368.59 / $4,029.28
| Facility | | $1,400.00 | $2,368.59 | $4,029.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.46 / $2,596.61 / $4,080.84
| Professional | | $2,277.46 | $2,596.61 | $4,080.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.68 / $3,120.38 / $3,399.71
| Facility | | $2,671.68 | $3,120.38 | $3,399.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.53 / $3,021.96 / $3,021.96
| Professional | | $1,550.53 | $3,021.96 | $3,021.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,864.64 / $2,864.64 / $2,864.64
| Facility | | $2,864.64 | $2,864.64 | $2,864.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.44 / $3,525.62 / $7,761.65
| Professional | | $2,400.44 | $3,525.62 | $7,761.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.93 / $2,560.21 / $3,995.59
| Professional | | $1,733.93 | $2,560.21 | $3,995.59 |