- 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
- $489.78 / $537.03 / $1,258.93
| Professional | | $489.78 | $537.03 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $436.52 / $870.96
| Professional | | $371.54 | $436.52 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $575.44 / $1,023.29
| Professional | | $389.05 | $575.44 | $1,023.29 |
- 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
- $346.74 / $501.19 / $776.25
| Professional | | $346.74 | $501.19 | $776.25 |