- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.00 / $2,306.26 / $3,324.00
| Facility | | $1,342.00 | $2,306.26 | $3,324.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.93 / $2,252.46 / $2,772.21
| Professional | | $1,732.93 | $2,252.46 | $2,772.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.36 / $2,517.94 / $2,666.06
| Professional | | $2,014.36 | $2,517.94 | $2,666.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.42 / $2,902.55 / $3,517.09
| Professional | | $2,056.42 | $2,902.55 | $3,517.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,896.00 / $5,455.00 / $12,000.00
| Facility | | $2,896.00 | $5,455.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.96 / $2,118.08 / $3,538.78
| Professional | | $1,766.96 | $2,118.08 | $3,538.78 |