- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Facility | | $1,096.48 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $3,981.07
| Professional | | $1,659.59 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,413.10 / $10,000.00
| Facility | | $6,309.57 | $7,413.10 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $2,951.21
| Professional | | $1,698.24 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $4,677.35
| Professional | | $1,621.81 | $2,290.87 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,265.80 / $6,918.31
| Facility | | $1,202.26 | $4,265.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,995.26 / $3,388.44
| Professional | | $1,584.89 | $1,995.26 | $3,388.44 |