- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $3,388.44
| Professional | | $1,071.52 | $1,258.93 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $2,041.74
| Professional | | $1,071.52 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,398.83
| Professional | | $1,380.38 | $1,584.89 | $2,398.83 |
- 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
- $954.99 / $1,445.44 / $2,754.23
| Professional | | $954.99 | $1,445.44 | $2,754.23 |