- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $436.52 / $1,202.26
| Professional | | $380.19 | $436.52 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $436.52 / $724.44
| Professional | | $389.05 | $436.52 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $616.60 / $870.96
| Professional | | $489.78 | $616.60 | $870.96 |
- 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
- $354.81 / $501.19 / $954.99
| Professional | | $354.81 | $501.19 | $954.99 |