- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $6,760.83
| Facility | | $1,949.84 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $2,511.89
| Professional | | $794.33 | $1,380.38 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,019.95 / $10,000.00
| Facility | | $1,412.54 | $3,019.95 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $2,951.21
| Professional | | $1,659.59 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $10,964.78
| Facility | | $5,128.61 | $8,128.31 | $10,964.78 |