- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,688.00 / $3,109.00
| Facility | | $1,277.00 | $1,688.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.55 / $1,364.36 / $1,692.16
| Professional | | $1,058.55 | $1,364.36 | $1,692.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.41 / $1,591.76 / $1,685.39
| Professional | | $1,273.41 | $1,591.76 | $1,685.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.92 / $1,743.96 / $2,412.02
| Professional | | $1,193.92 | $1,743.96 | $2,412.02 |
- 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
- $1,013.90 / $1,322.48 / $2,251.11
| Professional | | $1,013.90 | $1,322.48 | $2,251.11 |