- 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
- $645.65 / $741.31 / $1,995.26
| Professional | | $645.65 | $741.31 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $724.44 / $1,202.26
| Professional | | $616.60 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,479.11
| Professional | | $812.83 | $1,174.90 | $1,479.11 |
- 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
- $602.56 / $912.01 / $1,621.81
| Professional | | $602.56 | $912.01 | $1,621.81 |