- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $562.34 / $1,513.56
| Professional | | $489.78 | $562.34 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $575.44 / $933.25
| Professional | | $501.19 | $575.44 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,148.15
| Professional | | $630.96 | $758.58 | $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
- $436.52 / $645.65 / $1,230.27
| Professional | | $436.52 | $645.65 | $1,230.27 |