- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,786.30 / $7,079.46
| Facility | | $1,905.46 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $3,890.45
| Professional | | $1,096.48 | $1,659.59 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,754.23 / $10,000.00
| Facility | | $1,548.82 | $2,754.23 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $3,235.94
| Professional | | $2,398.83 | $2,818.38 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,964.78 / $15,848.93
| Facility | | $7,413.10 | $10,964.78 | $15,848.93 |