- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $851.14 / $1,949.84
| Professional | | $707.95 | $851.14 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $741.31 / $1,230.27
| Professional | | $562.34 | $741.31 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $851.14 / $1,513.56
| Professional | | $181.97 | $851.14 | $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
- $602.56 / $912.01 / $1,479.11
| Professional | | $602.56 | $912.01 | $1,479.11 |