- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,079.46
| Facility | | $1,698.24 | $4,073.80 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,290.87
| Professional | | $812.83 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,290.87 / $6,456.54
| Professional | | $977.24 | $2,290.87 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $2,818.38
| Professional | | $794.33 | $1,023.29 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $2,290.87
| Professional | | $933.25 | $1,096.48 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,000.00 / $26,302.68
| Facility | | $2,344.23 | $10,000.00 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $933.25 / $2,511.89
| Professional | | $645.65 | $933.25 | $2,511.89 |