- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $562.34 / $1,479.11
| Professional | | $489.78 | $562.34 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $562.34 / $912.01
| Professional | | $501.19 | $562.34 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $741.31 / $1,148.15
| Professional | | $630.96 | $741.31 | $1,148.15 |
- 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
- $467.74 / $660.69 / $1,202.26
| Professional | | $467.74 | $660.69 | $1,202.26 |