- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $891.25 / $1,949.84
| Professional | | $741.31 | $891.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,288.25
| Professional | | $645.65 | $758.58 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $1,698.24
| Professional | | $676.08 | $1,047.13 | $1,698.24 |
- 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
- $512.86 / $812.83 / $1,202.26
| Professional | | $512.86 | $812.83 | $1,202.26 |