- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $831.76 / $2,238.72
| Professional | | $724.44 | $831.76 | $2,238.72 |
- 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
- $181.97 / $954.99 / $1,513.56
| Professional | | $181.97 | $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 / $912.01 / $1,548.82
| Professional | | $645.65 | $912.01 | $1,548.82 |