- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $4,365.16
| Professional | | $1,995.26 | $2,398.83 | $4,365.16 |
- 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
- $1,659.59 / $2,570.40 / $3,019.95
| Professional | | $1,659.59 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $5,011.87
| Professional | | $1,698.24 | $2,454.71 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $3,630.78
| Professional | | $1,584.89 | $2,290.87 | $3,630.78 |