- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,398.83
| Facility | | $1,023.29 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,290.87
| Professional | | $1,047.13 | $1,348.96 | $2,290.87 |
- 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
- $912.01 / $1,288.25 / $1,548.82
| Professional | | $912.01 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $2,041.74
| Professional | | $912.01 | $1,148.15 | $2,041.74 |
- 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
- $851.14 / $1,096.48 / $1,819.70
| Professional | | $851.14 | $1,096.48 | $1,819.70 |