- 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
- $323.59 / $562.34 / $1,479.11
| Professional | | $323.59 | $562.34 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $831.76
| Professional | | $407.38 | $489.78 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $776.25 / $1,122.02
| Professional | | $371.54 | $776.25 | $1,122.02 |
- 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
- $501.19 / $645.65 / $1,071.52
| Professional | | $501.19 | $645.65 | $1,071.52 |