- 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
- $1,023.29 / $1,288.25 / $2,951.21
| Professional | | $1,023.29 | $1,288.25 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $1,949.84
| Professional | | $912.01 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $2,454.71
| Professional | | $977.24 | $1,445.44 | $2,454.71 |
- 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
- $831.76 / $1,230.27 / $1,778.28
| Professional | | $831.76 | $1,230.27 | $1,778.28 |