- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $3,801.89
| Facility | | $1,737.80 | $1,737.80 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,698.24
| Professional | | $912.01 | $1,258.93 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,388.44 / $5,011.87
| Facility | | $2,290.87 | $3,388.44 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $3,630.78 / $5,128.61
| Professional | | $851.14 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,818.38 / $10,000.00
| Facility | | $1,122.02 | $2,818.38 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,235.94 / $3,801.89
| Professional | | $2,344.23 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $3,019.95
| Professional | | $831.76 | $1,047.13 | $3,019.95 |