- 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
- $331.13 / $870.96 / $2,238.72
| Professional | | $331.13 | $870.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $660.69 / $1,862.09
| Professional | | $309.03 | $660.69 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $912.01 / $3,162.28
| Professional | | $281.84 | $912.01 | $3,162.28 |
- 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
- $354.81 / $1,096.48 / $2,187.76
| Professional | | $354.81 | $1,096.48 | $2,187.76 |