- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,570.40
| Professional | | $812.83 | $1,148.15 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $954.99 / $1,621.81
| Professional | | $724.44 | $954.99 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,096.48 / $1,995.26
| Professional | | $181.97 | $1,096.48 | $1,995.26 |
- 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
- $831.76 / $1,202.26 / $1,905.46
| Professional | | $831.76 | $1,202.26 | $1,905.46 |