- 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
- $537.03 / $616.60 / $1,737.80
| Professional | | $537.03 | $616.60 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $1,023.29
| Professional | | $524.81 | $616.60 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,071.52 / $1,288.25
| Professional | | $691.83 | $1,071.52 | $1,288.25 |
- 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
- $549.54 / $851.14 / $1,348.96
| Professional | | $549.54 | $851.14 | $1,348.96 |