- 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
- $812.83 / $954.99 / $2,137.96
| Professional | | $812.83 | $954.99 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,380.38
| Professional | | $691.83 | $812.83 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,122.02 / $1,819.70
| Professional | | $724.44 | $1,122.02 | $1,819.70 |
- 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
- $575.44 / $891.25 / $1,288.25
| Professional | | $575.44 | $891.25 | $1,288.25 |