- 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
- $512.86 / $562.34 / $1,348.96
| Professional | | $512.86 | $562.34 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $446.68 / $851.14
| Professional | | $380.19 | $446.68 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,071.52
| Professional | | $398.11 | $588.84 | $1,071.52 |
- 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
- $354.81 / $537.03 / $794.33
| Professional | | $354.81 | $537.03 | $794.33 |