- 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
- $251.19 / $457.09 / $1,096.48
| Professional | | $251.19 | $457.09 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $363.08 / $660.69
| Professional | | $309.03 | $363.08 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $588.84 / $851.14
| Professional | | $309.03 | $588.84 | $851.14 |
- 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
- $363.08 / $501.19 / $831.76
| Professional | | $363.08 | $501.19 | $831.76 |