- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $5,754.40
| Facility | | $1,698.24 | $2,511.89 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,677.35 / $5,888.44
| Professional | | $4,168.69 | $4,677.35 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,079.46 / $10,000.00
| Professional | | $3,235.94 | $7,079.46 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,786.30 / $9,120.11
| Professional | | $3,715.35 | $4,786.30 | $9,120.11 |