- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $3,235.94
| Professional | | $977.24 | $1,258.93 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,778.28
| Professional | | $794.33 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $1,348.96 / $2,137.96
| Professional | | $89.13 | $1,348.96 | $2,137.96 |
- 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
- $933.25 / $1,288.25 / $2,187.76
| Professional | | $933.25 | $1,288.25 | $2,187.76 |