- 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
- $691.83 / $891.25 / $2,290.87
| Professional | | $691.83 | $891.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $1,230.27
| Professional | | $562.34 | $758.58 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $954.99 / $1,513.56
| Professional | | $89.13 | $954.99 | $1,513.56 |
- 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
- $645.65 / $933.25 / $1,548.82
| Professional | | $645.65 | $933.25 | $1,548.82 |