- 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
- $446.68 / $630.96 / $1,621.81
| Professional | | $446.68 | $630.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $616.60 / $1,000.00
| Professional | | $457.09 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $776.25 / $1,230.27
| Professional | | $151.36 | $776.25 | $1,230.27 |
- 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
- $489.78 / $758.58 / $1,288.25
| Professional | | $489.78 | $758.58 | $1,288.25 |