- 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
- $501.19 / $645.65 / $1,819.70
| Professional | | $501.19 | $645.65 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $602.56 / $1,000.00
| Professional | | $446.68 | $602.56 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,412.54
| Professional | | $630.96 | $851.14 | $1,412.54 |
- 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
- $512.86 / $891.25 / $1,412.54
| Professional | | $512.86 | $891.25 | $1,412.54 |