- 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
- $1,949.84 / $2,570.40 / $3,311.31
| Professional | | $1,949.84 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $4,073.80 / $5,370.32
| Professional | | $0.02 | $4,073.80 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,311.31 / $5,623.41
| Professional | | $2,511.89 | $3,311.31 | $5,623.41 |
- 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
- $2,089.30 / $3,548.13 / $5,623.41
| Professional | | $2,089.30 | $3,548.13 | $5,623.41 |