- 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
- $467.74 / $537.03 / $1,513.56
| Professional | | $467.74 | $537.03 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $537.03 / $891.25
| Professional | | $478.63 | $537.03 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $1,122.02
| Professional | | $602.56 | $933.25 | $1,122.02 |
- 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
- $478.63 / $758.58 / $1,174.90
| Professional | | $478.63 | $758.58 | $1,174.90 |