- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $2,290.87
| Professional | | $724.44 | $870.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $776.25 / $1,288.25
| Professional | | $588.84 | $776.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $977.24 / $1,584.89
| Professional | | $181.97 | $977.24 | $1,584.89 |
- 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
- $676.08 / $954.99 / $1,621.81
| Professional | | $676.08 | $954.99 | $1,621.81 |