- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.00 / $2,342.54 / $3,513.81
| Facility | | $1,342.00 | $2,342.54 | $3,513.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.52 / $2,253.26 / $2,642.96
| Professional | | $1,713.52 | $2,253.26 | $2,642.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.02 / $2,603.78 / $2,756.94
| Professional | | $2,083.02 | $2,603.78 | $2,756.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.15 / $2,872.47 / $3,637.43
| Professional | | $1,871.15 | $2,872.47 | $3,637.43 |
- 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
- $1,555.16 / $2,258.64 / $3,672.90
| Professional | | $1,555.16 | $2,258.64 | $3,672.90 |