- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,326.86 / $3,960.46
| Facility | | $1,400.00 | $2,326.86 | $3,960.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.63 / $2,552.52 / $3,461.88
| Professional | | $2,237.63 | $2,552.52 | $3,461.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.19 / $3,067.09 / $3,341.64
| Facility | | $2,626.19 | $3,067.09 | $3,341.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.85 / $2,970.35 / $2,970.35
| Professional | | $1,523.85 | $2,970.35 | $2,970.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,814.58 / $2,814.58 / $2,814.58
| Facility | | $2,814.58 | $2,814.58 | $2,814.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.92 / $3,465.41 / $6,703.01
| Professional | | $2,359.92 | $3,465.41 | $6,703.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.83 / $2,656.63 / $3,960.46
| Professional | | $1,846.83 | $2,656.63 | $3,960.46 |