- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,230.27 / $3,090.30
| Professional | | $707.95 | $1,230.27 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $954.99 / $1,862.09
| Professional | | $812.83 | $954.99 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $2,238.72
| Professional | | $1,000.00 | $1,445.44 | $2,238.72 |
- 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
- $1,023.29 / $1,412.54 / $2,137.96
| Professional | | $1,023.29 | $1,412.54 | $2,137.96 |