- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,821.00 / $3,109.00
| Facility | | $1,277.00 | $1,821.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.82 / $1,758.25 / $1,969.21
| Professional | | $1,377.82 | $1,758.25 | $1,969.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.99 / $2,022.35 / $2,022.35
| Professional | | $1,527.99 | $2,022.35 | $2,022.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.12 / $2,343.78 / $2,661.09
| Professional | | $1,671.12 | $2,343.78 | $2,661.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,896.00 / $5,706.17 / $12,000.00
| Facility | | $2,896.00 | $5,706.17 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.21 / $1,687.88 / $2,865.07
| Professional | | $1,325.21 | $1,687.88 | $2,865.07 |