- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $724.44 / $1,698.24
| Professional | | $478.63 | $724.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $630.96 / $1,174.90
| Professional | | $446.68 | $630.96 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,479.11
| Professional | | $588.84 | $870.96 | $1,479.11 |
- 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
- $501.19 / $758.58 / $1,445.44
| Professional | | $501.19 | $758.58 | $1,445.44 |