- 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
- $724.44 / $933.25 / $2,570.40
| Professional | | $724.44 | $933.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $1,513.56
| Professional | | $831.76 | $933.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $1,905.46
| Professional | | $1,047.13 | $1,412.54 | $1,905.46 |
- 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
- $776.25 / $1,122.02 / $2,089.30
| Professional | | $776.25 | $1,122.02 | $2,089.30 |