- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,248.07 / $12,589.25
| Facility | | $3,715.35 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,365.16 / $6,309.57
| Professional | | $2,818.38 | $4,365.16 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $10,000.00
| Facility | | $4,073.80 | $5,011.87 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $5,754.40
| Professional | | $2,691.53 | $3,548.13 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $11,220.18 / $11,220.18
| Professional | | $2,089.30 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $2,137.96
| Professional | | $1,348.96 | $1,348.96 | $2,137.96 |