- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.00 / $2,676.00 / $3,406.28
| Facility | | $1,342.00 | $2,676.00 | $3,406.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.04 / $3,019.81 / $3,908.05
| Professional | | $2,232.04 | $3,019.81 | $3,908.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,593.94 / $3,242.43 / $3,433.16
| Professional | | $2,593.94 | $3,242.43 | $3,433.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.02 / $3,897.27 / $4,559.35
| Professional | | $2,543.02 | $3,897.27 | $4,559.35 |
- 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
- $2,263.17 / $2,786.95 / $4,619.89
| Professional | | $2,263.17 | $2,786.95 | $4,619.89 |