- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $2,951.21
| Professional | | $1,047.13 | $1,288.25 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,862.09
| Professional | | $831.76 | $1,096.48 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,258.93 / $2,238.72
| Professional | | $181.97 | $1,258.93 | $2,238.72 |
- 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
- $977.24 / $1,380.38 / $2,187.76
| Professional | | $977.24 | $1,380.38 | $2,187.76 |