- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,456.54 / $10,715.19
| Facility | | $2,951.21 | $6,456.54 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $977.24 / $3,715.35
| Professional | | $389.05 | $977.24 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $707.95 / $1,258.93
| Professional | | $302.00 | $707.95 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $812.83 / $2,290.87
| Professional | | $263.03 | $812.83 | $2,290.87 |
- 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
- $398.11 / $870.96 / $1,862.09
| Professional | | $398.11 | $870.96 | $1,862.09 |