- 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
- $151.36 / $218.78 / $489.78
| Professional | | $151.36 | $218.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $208.93 / $346.74
| Professional | | $151.36 | $208.93 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $275.42 / $426.58
| Professional | | $194.98 | $275.42 | $426.58 |
- 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
- $151.36 / $229.09 / $398.11
| Professional | | $151.36 | $229.09 | $398.11 |