- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $2,344.23
| Professional | | $691.83 | $912.01 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,380.38
| Professional | | $660.69 | $870.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,995.26
| Professional | | $1,000.00 | $1,288.25 | $1,995.26 |
- 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
- $741.31 / $1,258.93 / $1,995.26
| Professional | | $741.31 | $1,258.93 | $1,995.26 |