- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $1,445.44
| Professional | | $549.54 | $660.69 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $588.84 / $954.99
| Professional | | $436.52 | $588.84 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $645.65 / $1,174.90
| Professional | | $181.97 | $645.65 | $1,174.90 |
- 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
- $489.78 / $707.95 / $1,230.27
| Professional | | $489.78 | $707.95 | $1,230.27 |