- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $1,995.26
| Professional | | $660.69 | $776.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $1,258.93
| Professional | | $660.69 | $776.25 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,548.82
| Professional | | $870.96 | $1,148.15 | $1,548.82 |
- 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
- $630.96 / $933.25 / $1,698.24
| Professional | | $630.96 | $933.25 | $1,698.24 |