- 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
- $741.31 / $851.14 / $2,344.23
| Professional | | $741.31 | $851.14 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $851.14 / $1,412.54
| Professional | | $758.58 | $851.14 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,288.25 / $1,737.80
| Professional | | $954.99 | $1,288.25 | $1,737.80 |
- 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
- $691.83 / $1,023.29 / $1,905.46
| Professional | | $691.83 | $1,023.29 | $1,905.46 |