- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $10,000.00
| Facility | | $2,089.30 | $2,818.38 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,513.56 / $2,398.83
| Professional | | $354.81 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,467.37 / $4,897.79
| Facility | | $2,041.74 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $2,187.76 / $4,786.30
| Facility | | $331.13 | $2,187.76 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,949.84 / $1,949.84
| Facility | | $812.83 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $2,754.23
| Professional | | $812.83 | $977.24 | $2,754.23 |