- 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
- $812.83 / $1,023.29 / $2,344.23
| Professional | | $812.83 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $851.14 / $1,445.44
| Professional | | $645.65 | $851.14 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $977.24 / $1,737.80
| Professional | | $181.97 | $977.24 | $1,737.80 |
- 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
- $707.95 / $1,071.52 / $1,698.24
| Professional | | $707.95 | $1,071.52 | $1,698.24 |