- 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
- $2,454.71 / $3,162.28 / $5,623.41
| Professional | | $2,454.71 | $3,162.28 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,413.10 / $10,000.00
| Facility | | $6,165.95 | $7,413.10 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,548.13 / $4,570.88
| Professional | | $2,511.89 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,715.35 / $5,248.07
| Professional | | $1,698.24 | $3,715.35 | $5,248.07 |
- 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
- $1,995.26 / $2,691.53 / $4,466.84
| Professional | | $1,995.26 | $2,691.53 | $4,466.84 |