- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,956.84 / $3,109.00
| Facility | | $1,277.00 | $1,956.84 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.30 / $1,956.84 / $2,276.32
| Professional | | $1,451.30 | $1,956.84 | $2,276.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.09 / $2,133.86 / $2,259.38
| Professional | | $1,707.09 | $2,133.86 | $2,259.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.38 / $2,528.73 / $3,025.00
| Professional | | $1,764.38 | $2,528.73 | $3,025.00 |
- 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
- $1,458.39 / $2,045.99 / $3,031.85
| Professional | | $1,458.39 | $2,045.99 | $3,031.85 |