- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $239.88 / $354.81
| Professional | | $213.80 | $239.88 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,888.44 / $7,413.10
| Facility | | $4,365.16 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $354.81 / $562.34
| Professional | | $251.19 | $354.81 | $562.34 |