- 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 / $3,090.30 / $5,248.07
| Professional | | $2,454.71 | $3,090.30 | $5,248.07 |
- 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
- $2,137.96 / $3,090.30 / $4,073.80
| Professional | | $2,137.96 | $3,090.30 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,235.94 / $4,677.35
| Professional | | $1,698.24 | $3,235.94 | $4,677.35 |
- 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
- $2,041.74 / $2,691.53 / $4,466.84
| Professional | | $2,041.74 | $2,691.53 | $4,466.84 |