- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,365.16 / $4,897.79
| Facility | | $1,258.93 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $1,412.54
| Professional | | $1,096.48 | $1,288.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $2,570.40
| Facility | | $1,380.38 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,995.26 / $10,000.00
| Professional | | $1,202.26 | $1,995.26 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,089.30 / $3,715.35
| Professional | | $1,348.96 | $2,089.30 | $3,715.35 |