- 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
- $1,096.48 / $1,096.48 / $1,995.26
| Professional | | $1,096.48 | $1,096.48 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,244.36 / $10,000.00
| Facility | | $6,165.95 | $7,244.36 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $7,079.46
| Facility | | $1,479.11 | $4,365.16 | $7,079.46 |