- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $724.44 / $1,698.24
| Professional | | $660.69 | $724.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $588.84 / $1,148.15
| Professional | | $489.78 | $588.84 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $1,380.38
| Professional | | $512.86 | $758.58 | $1,380.38 |
- 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
- $467.74 / $676.08 / $1,023.29
| Professional | | $467.74 | $676.08 | $1,023.29 |