- 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
- $478.63 / $588.84 / $1,584.89
| Professional | | $478.63 | $588.84 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $588.84 / $1,047.13
| Professional | | $524.81 | $588.84 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,202.26
| Professional | | $660.69 | $851.14 | $1,202.26 |
- 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
- $467.74 / $691.83 / $1,318.26
| Professional | | $467.74 | $691.83 | $1,318.26 |