- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,079.46 / $7,079.46
| Facility | | $3,467.37 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $1,949.84
| Professional | | $645.65 | $724.44 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $1,202.26
| Professional | | $645.65 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,513.56
| Professional | | $812.83 | $1,096.48 | $1,513.56 |
- 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
- $616.60 / $891.25 / $1,584.89
| Professional | | $616.60 | $891.25 | $1,584.89 |