- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,434.00 / $1,993.83 / $3,500.00
| Facility | | $1,434.00 | $1,993.83 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.17 / $1,953.14 / $2,273.69
| Professional | | $1,407.17 | $1,953.14 | $2,273.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.15 / $2,102.69 / $2,226.38
| Professional | | $1,682.15 | $2,102.69 | $2,226.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.62 / $2,374.28 / $2,956.01
| Professional | | $1,725.62 | $2,374.28 | $2,956.01 |
- 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
- $1,452.84 / $1,878.13 / $3,028.72
| Professional | | $1,452.84 | $1,878.13 | $3,028.72 |