- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,370.32 / $9,549.93
| Facility | | $4,168.69 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $5,888.44
| Professional | | $2,570.40 | $3,235.94 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,365.16 / $10,000.00
| Facility | | $1,513.56 | $4,365.16 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,890.45 / $5,623.41
| Professional | | $2,398.83 | $3,890.45 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,365.16 / $7,244.36
| Professional | | $2,511.89 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,019.95 / $5,370.32
| Professional | | $2,511.89 | $3,019.95 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $6,760.83
| Professional | | $2,630.27 | $3,548.13 | $6,760.83 |