- 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
- $416.87 / $562.34 / $1,047.13
| Professional | | $416.87 | $562.34 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $478.63 / $724.44
| Professional | | $363.08 | $478.63 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $537.03 / $1,000.00
| Professional | | $338.84 | $537.03 | $1,000.00 |
- 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
- $346.74 / $537.03 / $831.76
| Professional | | $346.74 | $537.03 | $831.76 |