- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,344.23
| Professional | | $645.65 | $912.01 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,445.44
| Professional | | $660.69 | $870.96 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,096.48 / $1,778.28
| Professional | | $151.36 | $1,096.48 | $1,778.28 |
- 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
- $741.31 / $1,096.48 / $1,862.09
| Professional | | $741.31 | $1,096.48 | $1,862.09 |