- 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
- $549.54 / $630.96 / $1,698.24
| Professional | | $549.54 | $630.96 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $645.65 / $1,047.13
| Professional | | $562.34 | $645.65 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $891.25 / $1,318.26
| Professional | | $707.95 | $891.25 | $1,318.26 |
- 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
- $501.19 / $741.31 / $1,380.38
| Professional | | $501.19 | $741.31 | $1,380.38 |