- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $3,109.00 / $5,818.20
| Facility | | $1,277.00 | $3,109.00 | $5,818.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,482.81 / $3,259.43 / $4,431.80
| Professional | | $2,482.81 | $3,259.43 | $4,431.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.56 / $3,690.70 / $3,907.80
| Professional | | $2,952.56 | $3,690.70 | $3,907.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,897.60 / $4,065.04 / $5,680.10
| Professional | | $2,897.60 | $4,065.04 | $5,680.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,741.00 / $5,987.70 / $12,000.00
| Facility | | $3,741.00 | $5,987.70 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.35 / $3,204.57 / $5,335.08
| Professional | | $2,405.35 | $3,204.57 | $5,335.08 |