- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.00 / $2,390.35 / $3,324.00
| Facility | | $1,342.00 | $2,390.35 | $3,324.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.34 / $2,151.67 / $2,916.75
| Professional | | $1,790.34 | $2,151.67 | $2,916.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.13 / $2,633.91 / $2,788.85
| Professional | | $2,107.13 | $2,633.91 | $2,788.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.15 / $2,997.13 / $3,701.62
| Professional | | $2,232.15 | $2,997.13 | $3,701.62 |
- 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
- $1,838.73 / $2,587.69 / $4,047.06
| Professional | | $1,838.73 | $2,587.69 | $4,047.06 |