- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,762.47
| Facility | | $1,698.24 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,025.60 / $10,232.93
| Professional | | $3,235.94 | $6,025.60 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,760.83 / $7,585.78
| Professional | | $5,623.41 | $6,760.83 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,715.19
| Professional | | $10,000.00 | $10,000.00 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,606.93 / $13,803.84
| Professional | | $3,162.28 | $6,606.93 | $13,803.84 |