- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $5,248.07
| Facility | | $2,089.30 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $776.25 / $1,318.26
| Professional | | $269.15 | $776.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $575.44 / $1,071.52
| Professional | | $239.88 | $575.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $676.08 / $1,737.80
| Professional | | $199.53 | $676.08 | $1,737.80 |
- 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
- $331.13 / $660.69 / $1,348.96
| Professional | | $331.13 | $660.69 | $1,348.96 |