- 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
- $398.11 / $512.86 / $1,412.54
| Professional | | $398.11 | $512.86 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $524.81 / $851.14
| Professional | | $467.74 | $524.81 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $707.95 / $1,071.52
| Professional | | $575.44 | $707.95 | $1,071.52 |
- 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
- $407.38 / $602.56 / $1,122.02
| Professional | | $407.38 | $602.56 | $1,122.02 |